=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811190028
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN DOUGLAS BREHM PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2007
-----------------------------------------------------
Last Update Date | 02/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3747 W FORK RD
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45247-7548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-961-4335
-----------------------------------------------------
Fax | 513-961-4227
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3747 W FORK RD
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45247-7548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-961-4335
-----------------------------------------------------
Fax | 513-961-4227
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 2613
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------