Provider Demographics
NPI:1922090257
Name:BRISLIN, KENNETH J (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:BRISLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 848269
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-8269
Mailing Address - Country:US
Mailing Address - Phone:610-973-1700
Mailing Address - Fax:610-973-1778
Practice Address - Street 1:250 CETRONIA ROAD
Practice Address - Street 2:SUITE 303
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-9168
Practice Address - Country:US
Practice Address - Phone:610-973-6200
Practice Address - Fax:610-973-6546
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD074181L207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1637940OtherBLUE SHIELD
PA1011059120001Medicaid
PAP3462562OtherOXFORD
PA7716478OtherAETNA
PA2312743000OtherKEYSTONE EAST
PA89078OtherGEISINGER
PA2000705OtherKEYSTONE CENTRAL
PA821238OtherFIRST PRIORITY HEALTH
PA1637940OtherAMERIHEALTH ADMIN
PA50041754OtherBLUE CROSS
PAP00146237OtherRAILROAD MEDICARE
PAP3462562OtherOXFORD
081471Medicare PIN