Provider Demographics
NPI:1295751394
Name:SKILLICORN, BRIAN J (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:J
Last Name:SKILLICORN
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 1:9825 KENWOOD RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-6251
Mailing Address - Country:US
Mailing Address - Phone:513-872-4500
Mailing Address - Fax:513-527-0416
Practice Address - Street 1:9825 KENWOOD RD
Practice Address - Street 2:SUITE 105
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-6251
Practice Address - Country:US
Practice Address - Phone:513-872-4500
Practice Address - Fax:513-527-0416
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA907902085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2686964Medicaid
KY7100039440Medicaid
IN200842630Medicaid
OH4188951Medicare PIN
OH4188952Medicare PIN
OHP00332113Medicare PIN
OH2686964Medicaid
OH4188955Medicare PIN
OH4188956Medicare PIN
OH4188953Medicare PIN
KY7100039440Medicaid