Healthcare Provider Details

I. General information

NPI: 1699193508
Provider Name (Legal Business Name): BRYAN DANIEL BAILLIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2014
Last Update Date: 10/31/2020
Certification Date: 10/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5779 WOOSTER PIKE
MEDINA OH
44256-8816
US

IV. Provider business mailing address

5783 WOOSTER PIKE
MEDINA OH
44256-8816
US

V. Phone/Fax

Practice location:
  • Phone: 330-725-0569
  • Fax: 330-662-0258
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number35.132996
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35.132996
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: