1750379707 NPI number — PHILLIPS RESPESS BRYAN JR. MD

Table of content: PHILLIPS RESPESS BRYAN JR. MD (NPI 1750379707)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750379707 NPI number — PHILLIPS RESPESS BRYAN JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRYAN
Provider First Name:
PHILLIPS
Provider Middle Name:
RESPESS
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRYAN
Provider Other First Name:
PHILLIPS
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1750379707
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
70 MEDICAL CENTER CIR
Provider Second Line Business Mailing Address:
SUITE 208
Provider Business Mailing Address City Name:
FISHERSVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22939-2273
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-332-5926
Provider Business Mailing Address Fax Number:
540-332-5930

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
70 MEDICAL CENTER CIR
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
FISHERSVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22939-2273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-332-5926
Provider Business Practice Location Address Fax Number:
540-332-5930
Provider Enumeration Date:
10/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  0101019811 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 011345 . This is a "BCBS ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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