1760801740 NPI number — KEISHA KADESHA BRYANT MD

Table of content: KEISHA KADESHA BRYANT MD (NPI 1760801740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760801740 NPI number — KEISHA KADESHA BRYANT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRYANT
Provider First Name:
KEISHA
Provider Middle Name:
KADESHA
Provider Name Prefix Text:
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:
KELLY
Provider Other First Name:
KEISHA
Provider Other Middle Name:
K
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760801740
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
327 BEACH 19TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAR ROCKAWAY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11691-4423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-869-7000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
506 6TH ST
Provider Second Line Business Practice Location Address:
DEPARTMENT OF INTERNAL MEDICINE
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11215-3609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-203-2325
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/07/2014

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:  289760 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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