Provider Demographics
NPI:1710983622
Name:COLE, BRIAN G (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:G
Last Name:COLE
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 1:441 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2482
Mailing Address - Country:US
Mailing Address - Phone:419-221-3072
Mailing Address - Fax:419-225-8095
Practice Address - Street 1:405 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KENTON
Practice Address - State:OH
Practice Address - Zip Code:43326-1375
Practice Address - Country:US
Practice Address - Phone:419-679-5994
Practice Address - Fax:419-679-1088
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-6562-C207Q00000X
IN01040465A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0967271Medicaid
OH0967271Medicaid
OH0759171Medicare PIN