1053473710 NPI number — MRS. TIFFANY A BRYAN DPT

Table of content: MRS. TIFFANY A BRYAN DPT (NPI 1053473710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053473710 NPI number — MRS. TIFFANY A BRYAN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRYAN
Provider First Name:
TIFFANY
Provider Middle Name:
A
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
QUINLAN
Provider Other First Name:
TIFFANY
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053473710
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11129 GOLDEN SILENCE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERVIEW
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33579-2344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-543-0534
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3411 UNIVERSITY AVE STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26505-7219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-598-3221
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/15/2006

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: 225100000X , with the licence number:  WV002345 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 28975 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1063610 . This is a "WORKERS COMP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 7607536 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 311504453 . This is a "ACORDIA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 311504453 . This is a "CIGNA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3810000-211 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1714910 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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