Basic Information
| Provider Information | |||||||||
| NPI: | 1437639341 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRIM | ||||||||
| FirstName: | KYLE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 208 HYDE PARK PL | ||||||||
| Address2: | |||||||||
| City: | YARDLEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190675804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152085366 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 S FRONT ST | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171012010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177823131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2018 | ||||||||
| LastUpdateDate: | 01/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | MA060030 | PA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 363AM0700X | MA060030 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | OA004579 | 01 | PA | OSTEOPATHIC PHYSICIAN ASSISTANT LICENSE | OTHER | MA060030 | 01 | PA | MEDICAL PHYSICIAN ASST LICENSE | OTHER |