Provider Demographics
NPI:1548289549
Name:MICHELOW, BRYAN J (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:J
Last Name:MICHELOW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3733 PARK EAST DR
Mailing Address - Street 2:107
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4338
Mailing Address - Country:US
Mailing Address - Phone:216-595-6800
Mailing Address - Fax:
Practice Address - Street 1:3733 PARK EAST DR
Practice Address - Street 2:107
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4338
Practice Address - Country:US
Practice Address - Phone:216-595-6800
Practice Address - Fax:216-593-0414
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062842M208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2019103Medicaid
OH0840332Medicare PIN