Healthcare Provider Details

I. General information

NPI: 1558879791
Provider Name (Legal Business Name): BRYAN J DIMATTEO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 01/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN ST
CINCINNATI OH
45219-2364
US

IV. Provider business mailing address

2128 ALPINE PL APT 5
CINCINNATI OH
45206-2669
US

V. Phone/Fax

Practice location:
  • Phone: 513-584-4194
  • Fax:
Mailing address:
  • Phone: 937-361-3401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberLE-00022018
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.019632
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: