Healthcare Provider Details

I. General information

NPI: 1902806748
Provider Name (Legal Business Name): DAVID BRINE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 MERCY DR NW
CANTON OH
44708-2614
US

IV. Provider business mailing address

PO BOX 20238
CANTON OH
44701-0238
US

V. Phone/Fax

Practice location:
  • Phone: 330-489-1070
  • Fax:
Mailing address:
  • Phone: 866-684-1492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35074325O
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: