Healthcare Provider Details

I. General information

NPI: 1881199669
Provider Name (Legal Business Name): KENNETH EDWARD BRILEY JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 NW 12TH AVE
MIAMI FL
33136-1002
US

IV. Provider business mailing address

1475 NW 12TH AVE
MIAMI FL
33136-1002
US

V. Phone/Fax

Practice location:
  • Phone: 305-243-5512
  • Fax: 305-243-4613
Mailing address:
  • Phone: 305-243-5512
  • Fax: 305-243-4613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number22166
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME145695
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: