Healthcare Provider Details

I. General information

NPI: 1740903822
Provider Name (Legal Business Name): BRYAN FALLIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2022
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

644 EDEN PARK DR
CINCINNATI OH
45202-6031
US

IV. Provider business mailing address

2300 CHAMBER CENTER DR STE 100
LAKESIDE PARK KY
41017-1686
US

V. Phone/Fax

Practice location:
  • Phone: 513-931-0083
  • Fax: 859-331-2449
Mailing address:
  • Phone: 859-331-2440
  • Fax: 859-689-0017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: BRYAN V FALLIS
Title or Position: PRESIDENT OWNER
Credential: DPM
Phone: 513-931-0083