MEDICARE: BROTHAS INC. YOUTH INITIATIVE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1447181425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROTHAS INC. YOUTH INITIATIVE

Provider Business Mailing Address
First Line	:	4245 REDWOOD TER
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45217-1825
Country	:	US
Telephone Number	:	937-856-6523
Fax Number	:

Provider Business Practice Location Address
First Line	:	4909 PADDOCK RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45237-5509
Country	:	US
Telephone Number	:	937-856-6523
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RONNELL ELLISON SR.
Credential	:
Telephone Number	:	937-856-6523

Provider Enumeration Date	:	05/27/2026
Last Update Date	:	05/27/2026

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