Provider Demographics
NPI:1275811259
Name:TOMBOW, BRIAN C
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:C
Last Name:TOMBOW
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 1:3115 KILLINGWORTH LN
Mailing Address - Street 2:
Mailing Address - City:TWINSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44087-2645
Mailing Address - Country:US
Mailing Address - Phone:330-685-2548
Mailing Address - Fax:
Practice Address - Street 1:3115 KILLINGWORTH LN
Practice Address - Street 2:
Practice Address - City:TWINSBURG
Practice Address - State:OH
Practice Address - Zip Code:44087-2645
Practice Address - Country:US
Practice Address - Phone:330-685-2548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3159933372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3159933Medicaid