Provider Demographics
NPI:1407907058
Name:KILBANE, BRENDAN J (MD)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:J
Last Name:KILBANE
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 1:3605 WARRENSVILLE CENTER ROAD
Mailing Address - Street 2:MSC 9152
Mailing Address - City:SHAKER HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122
Mailing Address - Country:US
Mailing Address - Phone:216-286-6299
Mailing Address - Fax:216-286-6341
Practice Address - Street 1:11100 EUCLID AVENUE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106
Practice Address - Country:US
Practice Address - Phone:216-844-7700
Practice Address - Fax:216-286-6341
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-1111852080P0204X
OH350823332080P0204X
OH35-0823332080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1407907058Medicaid
PA1021128310001Medicaid
IN200873430AMedicaid
OH2759395Medicaid
SCQ82333Medicaid
PA1021128310001Medicaid
OHKI4210331Medicare PIN