Healthcare Provider Details

I. General information

NPI: 1912139072
Provider Name (Legal Business Name): BRIAN J. CARLISLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2009
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

452 W 10TH AVE
COLUMBUS OH
43210-1240
US

IV. Provider business mailing address

700 ACKERMAN RD STE 2120
COLUMBUS OH
43202-1559
US

V. Phone/Fax

Practice location:
  • Phone: 614-293-2957
  • Fax: 614-685-6533
Mailing address:
  • Phone: 614-293-2957
  • Fax: 614-685-6533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35096903
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number35096903
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number35096903CTR
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: