Provider Demographics
NPI:1124224126
Name:TIMOTHY C. BRYAN, MD, PLC
Entity Type:Organization
Organization Name:TIMOTHY C. BRYAN, MD, PLC
Other - Org Name:GATEWAY FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-840-9155
Mailing Address - Street 1:4365 E PECOS RD
Mailing Address - Street 2:SUITE 134
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-8053
Mailing Address - Country:US
Mailing Address - Phone:480-840-9155
Mailing Address - Fax:480-840-9320
Practice Address - Street 1:4365 E PECOS RD
Practice Address - Street 2:SUITE 134
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-8053
Practice Address - Country:US
Practice Address - Phone:480-840-9155
Practice Address - Fax:480-840-9320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35487207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ104591Medicaid
AZ104591Medicaid
AZ112422412Medicare UPIN