Provider Demographics
NPI:1790721918
Name:SCHACK, BRIAN W (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:W
Last Name:SCHACK
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:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-654-2283
Mailing Address - Fax:859-654-2284
Practice Address - Street 1:79 COUNTRY CLUB DRIVE
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:KY
Practice Address - Zip Code:41006
Practice Address - Country:US
Practice Address - Phone:859-654-2283
Practice Address - Fax:859-654-2284
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35629208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64014483Medicaid
KY110208628OtherRAILROAD MEDICARE
OH2269736Medicaid
KYP00839846OtherRAILROAD MEDICARE
KYP00839846OtherRAILROAD MEDICARE
KY110208628OtherRAILROAD MEDICARE
KY0387224Medicare PIN