Provider Demographics
NPI:1407098023
Name:BRISLIN, RYAN KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:KEITH
Last Name:BRISLIN
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 1:305 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-1578
Mailing Address - Country:US
Mailing Address - Phone:740-532-3534
Mailing Address - Fax:740-532-0027
Practice Address - Street 1:1408 CAMPBELL DR STE 201
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-2301
Practice Address - Country:US
Practice Address - Phone:740-534-9195
Practice Address - Fax:740-534-9327
Is Sole Proprietor?:No
Enumeration Date:2009-03-27
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.096567208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0071860Medicaid
KY7100221840Medicaid
WV3810024385Medicaid