1932177557 NPI number — CYNTHIA BLACKWELL BRYAN

Table of content: CYNTHIA BLACKWELL BRYAN (NPI 1932177557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932177557 NPI number — CYNTHIA BLACKWELL BRYAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRYAN
Provider First Name:
CYNTHIA
Provider Middle Name:
BLACKWELL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1932177557
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 COLLEGE BLVD W
Provider Second Line Business Mailing Address:
SUITE G
Provider Business Mailing Address City Name:
NICEVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32578-1099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-897-1700
Provider Business Mailing Address Fax Number:
850-897-1792

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 WEST COLLEGE BOULEVARD
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
NICEVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32578-1049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-897-1700
Provider Business Practice Location Address Fax Number:
850-897-1792
Provider Enumeration Date:
03/09/2006

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:  ME80397 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 259143000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110233921 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 35711 . This is a "BLUE CROSS/BLUE SHIELD FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com