Basic Information
| Provider Information | |||||||||
| NPI: | 1861086522 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RADICAN | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | DAVID | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 781076 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | 3178651479 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 N DAN JONES RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | PLAINFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461682848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177817328 | ||||||||
| FaxNumber: | 3177817216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2021 | ||||||||
| LastUpdateDate: | 01/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 28201644A | IN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 71011453A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.