Provider Demographics
NPI:1609966159
Name:BRIAN PRZYSTAWSKI, DPM, PSC
Entity type:Organization
Organization Name:BRIAN PRZYSTAWSKI, DPM, PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:PRZYSTAWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:812-948-0211
Mailing Address - Street 1:PO BOX 708
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-0708
Mailing Address - Country:US
Mailing Address - Phone:812-945-3916
Mailing Address - Fax:812-944-3404
Practice Address - Street 1:2857 CHARLESTOWN RD STE 300
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-0005
Practice Address - Country:US
Practice Address - Phone:812-948-0211
Practice Address - Fax:812-948-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50003493Medicaid
KY80900202Medicaid
=========OtherHUMANA
IN=========001OtherANTHEM IN
KY80900202Medicaid
=========OtherTRICARE
KY80900202Medicaid
IN215680Medicare PIN
=========OtherTRICARE