Provider Demographics
NPI:1174195549
Name:CZERWONKA, BRIAN MATTHEW
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:MATTHEW
Last Name:CZERWONKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 WOODLAND HILLS DR STE 7
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:KY
Mailing Address - Zip Code:41071-2947
Mailing Address - Country:US
Mailing Address - Phone:502-619-9234
Mailing Address - Fax:
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-584-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH470795163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse