Provider Demographics
NPI:1205878857
Name:EWY, BRIAN RANDALL (DO)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:RANDALL
Last Name:EWY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23625 COMMERCE PARK
Mailing Address - Street 2:STE 204
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5845
Mailing Address - Country:US
Mailing Address - Phone:216-255-5743
Mailing Address - Fax:866-735-3451
Practice Address - Street 1:21 RIVERS EDGE DR
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-7739
Practice Address - Country:US
Practice Address - Phone:207-967-2745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS99502085R0202X
PAOS0153622085R0202X
ME18352085R0202X
TN585752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1025758980002Medicaid
KY7100081200Medicaid
NC7617011Medicaid
SCQ01835Medicaid
1205878857OtherTRICARE NORTH
LA1415863Medicaid
ME432215499Medicaid
KY7100081200Medicaid
MEME224907Medicare PIN
LA1415863Medicaid