=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013266774
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN LEE VEREB NP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2012
-----------------------------------------------------
Last Update Date | 01/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3562 RIDGE PARK DR STE. A
-----------------------------------------------------
City | FAIRLAWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44333-9294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-664-0767
-----------------------------------------------------
Fax | 330-665-4190
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3562 RIDGE PARK DR STE. A
-----------------------------------------------------
City | FAIRLAWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44333-9294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-664-0767
-----------------------------------------------------
Fax | 330-665-4190
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | COA.13794-NP
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------