Provider Demographics
NPI:1134273428
Name:BRIAN J NOVACK DPM INC
Entity type:Organization
Organization Name:BRIAN J NOVACK DPM INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:NOVACK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:440-944-6665
Mailing Address - Street 1:29630 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:WICKLIFFE
Mailing Address - State:OH
Mailing Address - Zip Code:44092-1829
Mailing Address - Country:US
Mailing Address - Phone:440-944-6665
Mailing Address - Fax:440-944-6672
Practice Address - Street 1:29630 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:WICKLIFFE
Practice Address - State:OH
Practice Address - Zip Code:44092-1829
Practice Address - Country:US
Practice Address - Phone:440-944-6665
Practice Address - Fax:440-944-6672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002998213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0111152Medicaid
OH4602080001Medicare NSC
OHDD0381Medicare PIN
OHBR9313001Medicare PIN
OH2146270Medicaid
OHP00269217OtherMEDICARE RAILROAD
OHBR9313001Medicare PIN
OH4602080001Medicare NSC
OH93061OtherQUAL
OHU77040Medicare UPIN
OH275645717008OtherMEDICAL MUTUAL
OHNO0881115OtherMEDICARE
OH4602080001Medicare NSC