Provider Demographics
NPI:1649405259
Name:BRYAN FALLIS
Entity Type:Organization
Organization Name:BRYAN FALLIS
Other - Org Name:PROGRESSIVE PODIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:V
Authorized Official - Last Name:FALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:513-931-0083
Mailing Address - Street 1:PO BOX 636389
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:513-931-0083
Mailing Address - Fax:859-331-2449
Practice Address - Street 1:1577 GOODMAN AVE STE A
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45224-1044
Practice Address - Country:US
Practice Address - Phone:513-931-0083
Practice Address - Fax:859-331-2449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-27
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000619072OtherANTHEM
OH2214213Medicaid
OH2955422Medicaid
OH2214213Medicaid
OH2955422Medicaid
OH6262030001Medicare NSC