Provider Demographics
NPI:1376863308
Name:BYRNE, BRIAN C (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:C
Last Name:BYRNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 N MERIDIAN ST
Mailing Address - Street 2:STE 500 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-3908
Mailing Address - Country:US
Mailing Address - Phone:317-963-0860
Mailing Address - Fax:317-962-4950
Practice Address - Street 1:1111 RONALD REAGAN PKWY
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7085
Practice Address - Country:US
Practice Address - Phone:317-217-3500
Practice Address - Fax:317-217-3115
Is Sole Proprietor?:No
Enumeration Date:2010-06-01
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11015526A390200000X
IN01070319A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201083530Medicaid
IN201083530Medicaid