Provider Demographics
NPI:1235243023
Name:BRYAN C. DAVIS, M.D., P.A.
Entity Type:Organization
Organization Name:BRYAN C. DAVIS, M.D., P.A.
Other - Org Name:FAMILY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:620-221-9500
Mailing Address - Street 1:1305 E 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:KS
Mailing Address - Zip Code:67156-5201
Mailing Address - Country:US
Mailing Address - Phone:620-221-9500
Mailing Address - Fax:620-221-3700
Practice Address - Street 1:1305 E 19TH AVE
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:KS
Practice Address - Zip Code:67156-5201
Practice Address - Country:US
Practice Address - Phone:620-221-9500
Practice Address - Fax:620-221-3700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
04-27652207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100327700CMedicaid
KS336640OtherFIRSTGUARD
KS130330OtherBC/BS OF KANSAS
KSG85252Medicare UPIN
KS110411Medicare ID - Type Unspecified