Provider Demographics
NPI:1225016835
Name:JELLISON, BRIAN JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JAY
Last Name:JELLISON
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 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-2060
Mailing Address - Fax:414-259-9290
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-2060
Practice Address - Fax:414-259-9290
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2234522085R0202X
IN01061964A2085R0202X
NMMD2008-01422085R0202X
WI464062085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000393004OtherANTHEM-352047427
WI1225016835Medicaid
MA2101688Medicaid
INP00331579OtherRR MEDICARE-351158723
IN073863OtherSIHO-351158723
IN000000492351OtherANTHEM 203778927
MA468500OtherTUFTS HEALTH PLAN
MAJ28632OtherBCBS OF MA
IN000000393001OtherANTHEM-351158723
IN073867OtherSIHO-352047427
IN200828930Medicaid
NM92753337Medicaid
INQ0433404OtherSHOCMO351158723-352047427
IN026010NNNMedicare ID - Type Unspecified351158723
IN200828930Medicaid
MA2101688Medicaid
NM300229Medicare PIN
MA468500OtherTUFTS HEALTH PLAN