Healthcare Provider Details

I. General information

NPI: 1417513367
Provider Name (Legal Business Name): BRIAN JOSEPH KASSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 BELMONT AVE # MEDED2S
YOUNGSTOWN OH
44504-1006
US

IV. Provider business mailing address

1100 BOARDMAN CANFIELD RD APT 74C
BOARDMAN OH
44512-8054
US

V. Phone/Fax

Practice location:
  • Phone: 330-480-2994
  • Fax:
Mailing address:
  • Phone: 248-860-8662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number58.031112
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number58.031112
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: