Provider Demographics
NPI: | 1669474649 |
---|---|
Name: | CECCARELLI, BRIAN J (D O) |
Entity Type: | Individual |
Prefix: | |
First Name: | BRIAN |
Middle Name: | J |
Last Name: | CECCARELLI |
Suffix: | |
Gender: | M |
Credentials: | D O |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 713130 |
Mailing Address - Street 2: | |
Mailing Address - City: | CINCINNATI |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 45271-0001 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 937-415-9100 |
Mailing Address - Fax: | 937-415-9191 |
Practice Address - Street 1: | 4160 LITTLE YORK RD |
Practice Address - Street 2: | STE. 10 |
Practice Address - City: | DAYTON |
Practice Address - State: | OH |
Practice Address - Zip Code: | 45414-5800 |
Practice Address - Country: | US |
Practice Address - Phone: | 937-415-9100 |
Practice Address - Fax: | 937-415-9191 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-08-10 |
Last Update Date: | 2011-10-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | 3891 | 207X00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 0739008 | Medicaid | |
OH | P00657291 | Other | RR MEDICARE |
OH | 200021341 | Other | RAILROAD MEDICARE |
OH | CE0638922 | Medicare ID - Type Unspecified | |
OH | E29655 | Medicare UPIN | |
OH | CE7284331 | Medicare PIN |