Provider Demographics
NPI:1922289875
Name:MARK S. BRIGHAM, DO, INC.
Entity Type:Organization
Organization Name:MARK S. BRIGHAM, DO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARCILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSHAVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-336-8717
Mailing Address - Street 1:195 WADSWORTH RD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-9504
Mailing Address - Country:US
Mailing Address - Phone:330-336-8717
Mailing Address - Fax:330-335-0092
Practice Address - Street 1:195 WADSWORTH RD
Practice Address - Street 2:SUITE 401
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-9504
Practice Address - Country:US
Practice Address - Phone:330-336-8717
Practice Address - Fax:330-335-0092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005567207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2809250Medicaid
OH0180398Medicaid
OH2809250Medicaid
OH9311091Medicare PIN