Healthcare Provider Details

I. General information

NPI: 1184993776
Provider Name (Legal Business Name): MATTHEW PHILLIP BRILL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2011
Last Update Date: 07/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 S CONGRESS AVE
ATLANTIS FL
33462-1149
US

IV. Provider business mailing address

5301 S CONGRESS AVE
ATLANTIS FL
33462-1149
US

V. Phone/Fax

Practice location:
  • Phone: 561-601-9191
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number5190
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberUO2767
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number39072
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOS14534
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: