Healthcare Provider Details

I. General information

NPI: 1891920773
Provider Name (Legal Business Name): BRANDON BLAKE CONINE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2009
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN ST EMERGENCY MEDICINE
CINCINNATI OH
45219-2364
US

IV. Provider business mailing address

3200 BURNET AVENUE, 3 SOUTH CENTRAL CREDENTIALING
CINCINNATI OH
45229-3019
US

V. Phone/Fax

Practice location:
  • Phone: 513-558-5281
  • Fax: 513-558-5791
Mailing address:
  • Phone: 513-558-5281
  • Fax: 513-558-5791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35 120143
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: