Provider Demographics
NPI:1679572234
Name:SUPPLEE, BRIAN GERALD (DC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:GERALD
Last Name:SUPPLEE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1156 DUBLIN RD
Mailing Address - Street 2:STE 102
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1095
Mailing Address - Country:US
Mailing Address - Phone:267-328-5918
Mailing Address - Fax:267-328-5918
Practice Address - Street 1:1156 DUBLIN RD
Practice Address - Street 2:STE 102
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1095
Practice Address - Country:US
Practice Address - Phone:267-328-5918
Practice Address - Fax:215-933-5290
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1465111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0339100Medicaid
OH0629773Medicare ID - Type Unspecified
OH0339100Medicaid