1548586118 NPI number — BRYAN JOSEPH ALLEN MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548586118 NPI number — BRYAN JOSEPH ALLEN MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

ALLEN

Provider First Name:

BRYAN

Provider Middle Name:

JOSEPH

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1548586118

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

03/16/2017

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

200 3RD AVE W

Provider Second Line Business Mailing Address:

SUITE 210

Provider Business Mailing Address City Name:

BRADENTON

Provider Business Mailing Address State Name:

FL

Provider Business Mailing Address Postal Code:

34205-8626

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

941-792-0340

Provider Business Mailing Address Fax Number:

941-794-2251

Provider First Line Business Practice Location Address:

2234 COLONIAL BLVD

Provider Second Line Business Practice Location Address:

ATTN: PAYER CONTRACTING & RELATIONS

Provider Business Practice Location Address City Name:

FORT MYERS

Provider Business Practice Location Address State Name:

FL

Provider Business Practice Location Address Postal Code:

33907-1412

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

239-931-7342

Provider Business Practice Location Address Fax Number:

239-931-7385

Provider Enumeration Date:

04/08/2010

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208800000X , with the licence number: ME120341 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 1192921 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: P1033007 . This is a "FREEDOM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: P01796855 . This is a "CLEAR HEALTH ALLIANCE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 150JQ . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 9438549 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: P01520110 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: P969301 . This is a "OPTIMUM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 015011500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
• Identifier: 4840869 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 015011500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".