Provider Demographics
NPI:1326240839
Name:STEVENS PARK CLINIC MEDICAL GROUP
Entity Type:Organization
Organization Name:STEVENS PARK CLINIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:214-943-4631
Mailing Address - Street 1:2100 W COLORADO BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75211-1900
Mailing Address - Country:US
Mailing Address - Phone:214-943-4631
Mailing Address - Fax:214-946-5334
Practice Address - Street 1:2100 W COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-1900
Practice Address - Country:US
Practice Address - Phone:214-943-4631
Practice Address - Fax:214-946-5334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2425207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144698103Medicaid
TX00500ROtherMEDICARE PTAN
TXG44258Medicare UPIN