Healthcare Provider Details

I. General information

NPI: 1023223781
Provider Name (Legal Business Name): BRIAN HARRIS ZACK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E ROYALTON RD STE 100
BROADVIEW HTS OH
44147-2592
US

IV. Provider business mailing address

PO BOX 8792
BELFAST ME
04915-8792
US

V. Phone/Fax

Practice location:
  • Phone: 440-526-6630
  • Fax: 440-526-1487
Mailing address:
  • Phone: 440-526-6630
  • Fax: 440-526-1487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35-093589
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: