Healthcare Provider Details

I. General information

NPI: 1205878857
Provider Name (Legal Business Name): BRIAN RANDALL EWY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 RIVERS EDGE DR
KENNEBUNK ME
04043-7739
US

IV. Provider business mailing address

23625 COMMERCE PARK STE 204
BEACHWOOD OH
44122-5845
US

V. Phone/Fax

Practice location:
  • Phone: 207-967-2745
  • Fax:
Mailing address:
  • Phone: 216-255-5743
  • Fax: 866-735-3451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOS9950
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOS015362
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number1835
License Number StateME
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number58575
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1025758980002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier7100081200
Identifier TypeMEDICAID
Identifier StateKY
Identifier Issuer
# 3
Identifier7617011
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 4
IdentifierQ01835
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer
# 5
Identifier1205878857
Identifier TypeOTHER
Identifier State
Identifier IssuerTRICARE NORTH
# 6
Identifier1415863
Identifier TypeMEDICAID
Identifier StateLA
Identifier Issuer
# 7
Identifier432215499
Identifier TypeMEDICAID
Identifier StateME
Identifier Issuer
# 8
Identifier009180200
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: