Provider Demographics
NPI:1164492930
Name:BRINE, BART J (MD)
Entity Type:Individual
Prefix:
First Name:BART
Middle Name:J
Last Name:BRINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1059 E STATE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460
Mailing Address - Country:US
Mailing Address - Phone:330-332-9991
Mailing Address - Fax:330-332-2188
Practice Address - Street 1:1059 E STATE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460
Practice Address - Country:US
Practice Address - Phone:330-332-9991
Practice Address - Fax:330-332-2188
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35068377207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0165548Medicaid
G06014Medicare UPIN
OH0165548Medicaid