Provider Demographics
NPI:1881255040
Name:ICE, BRIAN ANDREW
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:ANDREW
Last Name:ICE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-9031
Mailing Address - Country:US
Mailing Address - Phone:740-779-4570
Mailing Address - Fax:740-779-4579
Practice Address - Street 1:4437 STATE ROUTE 159 STE 125
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-7065
Practice Address - Country:US
Practice Address - Phone:740-779-4570
Practice Address - Fax:740-779-4579
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.024959363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0359821Medicaid