Provider Demographics
NPI:1891920773
Name:CONINE, BRANDON BLAKE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:BLAKE
Last Name:CONINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3200 BURNET AVENUE, 3 SOUTH
Mailing Address - Street 2:CENTRAL CREDENTIALING
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3019
Mailing Address - Country:US
Mailing Address - Phone:513-558-5281
Mailing Address - Fax:513-558-5791
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:EMERGENCY MEDICINE
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-558-5281
Practice Address - Fax:513-558-5791
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-21
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35 120143207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0077847Medicaid
IN7100252520Medicaid
OHH176861Medicare PIN