Healthcare Provider Details

I. General information

NPI: 1922090257
Provider Name (Legal Business Name): KENNETH J BRISLIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 01/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 CETRONIA ROAD SUITE 303
ALLENTOWN PA
18104-9168
US

IV. Provider business mailing address

PO BOX 848269
BOSTON MA
02284-8269
US

V. Phone/Fax

Practice location:
  • Phone: 610-973-6200
  • Fax: 610-973-6546
Mailing address:
  • Phone: 610-973-1700
  • Fax: 610-973-1778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD074181L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD074181L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: