1962419663 NPI number — MRS. MARY M BRYANT MD

Table of content: MRS. MARY M BRYANT MD (NPI 1962419663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962419663 NPI number — MRS. MARY M BRYANT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRYANT
Provider First Name:
MARY
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

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 Information

NPI Number:
1962419663
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4002 KRESGE WAY
Provider Second Line Business Mailing Address:
#100
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-897-1121
Provider Business Mailing Address Fax Number:
502-897-1189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4002 KRESGE WAY
Provider Second Line Business Practice Location Address:
#100
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-897-1121
Provider Business Practice Location Address Fax Number:
502-897-1189
Provider Enumeration Date:
08/02/2006

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: 207R00000X , with the licence number:  30713 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000051875 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64307135 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110165641 . This is a "RR" identifier . This identifiers is of the category "OTHER".