Provider Demographics
NPI:1003808924
Name:BRYAN, THORNTON E III (MD)
Entity Type:Individual
Prefix:DR
First Name:THORNTON
Middle Name:E
Last Name:BRYAN
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:615-597-5075
Practice Address - Street 1:701 E PARKCENTER BLVD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6528
Practice Address - Country:US
Practice Address - Phone:208-381-6500
Practice Address - Fax:208-381-6505
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000027731207Q00000X
LAMD.204465207Q00000X
IDM12455207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3804377Medicaid
MS05829798Medicaid
TN003038788OtherBCBS OF TN
LA2158082Medicaid
LA4Q3907061Medicare PIN
TN003038788OtherBCBS OF TN
TN3804377Medicaid