Basic Information
| Provider Information | |||||||||
| NPI: | 1205878857 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EWY | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | RANDALL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23625 COMMERCE PARK | ||||||||
| Address2: | STE 204 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162555743 | ||||||||
| FaxNumber: | 8667353451 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 RIVERS EDGE DR | ||||||||
| Address2: | |||||||||
| City: | KENNEBUNK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040437739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079672745 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 58575 | TN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 1835 | ME | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | OS9950 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1415863 | 05 | LA | MEDICAID | 7100081200 | 05 | KY | MEDICAID | 7617011 | 05 | NC | MEDICAID | 432215499 | 05 | ME | MEDICAID | Q01835 | 05 | SC | MEDICAID | 1205878857 | 01 | TRICARE NORTH | OTHER | 1025758980002 | 05 | PA | MEDICAID |