Provider Demographics
NPI:1740903822
Name:BRYAN FALLIS
Entity type:Organization
Organization Name:BRYAN FALLIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT 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:513-931-0083
Mailing Address - Street 1:2300 CHAMBER CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE PARK
Mailing Address - State:KY
Mailing Address - Zip Code:41017-1686
Mailing Address - Country:US
Mailing Address - Phone:859-331-2440
Mailing Address - Fax:859-689-0017
Practice Address - Street 1:644 EDEN PARK DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45202-6031
Practice Address - Country:US
Practice Address - Phone:513-931-0083
Practice Address - Fax:859-331-2449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6262030006OtherMEDICARE NSC