Provider Demographics
NPI:1205860459
Name:WEST MEMPHIS EYE CENTER, PA
Entity Type:Organization
Organization Name:WEST MEMPHIS EYE CENTER, PA
Other - Org Name:GLEN EDWARD BRYANT JR.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:870-732-2100
Mailing Address - Street 1:303 W POLK
Mailing Address - Street 2:SUITE A
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301
Mailing Address - Country:US
Mailing Address - Phone:870-732-2100
Mailing Address - Fax:870-732-3027
Practice Address - Street 1:303 W POLK
Practice Address - Street 2:SUITE A
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301
Practice Address - Country:US
Practice Address - Phone:870-732-2100
Practice Address - Fax:870-732-3027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102003001Medicaid
AR111786002Medicaid
57162Medicare ID - Type Unspecified