Provider Demographics
NPI:1720314966
Name:BRYAN FALLIS
Entity Type:Organization
Organization Name:BRYAN FALLIS
Other - Org Name:PROGRESSIVE PODIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:V
Authorized Official - Last Name:FALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:859-331-2440
Mailing Address - Street 1:PO BOX 636389
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:859-557-4260
Mailing Address - Fax:513-557-3347
Practice Address - Street 1:2300 CHAMBER CENTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKESIDE PARK
Practice Address - State:KY
Practice Address - Zip Code:41017-1673
Practice Address - Country:US
Practice Address - Phone:859-331-2440
Practice Address - Fax:859-331-2449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-22
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00258213E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100096290Medicaid
KY80000151Medicaid
KY6262030002Medicare NSC
KY7100096290Medicaid
KY80000151Medicaid