Provider Demographics
NPI:1417000100
Name:BRYAN, ALVIN B JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ALVIN
Middle Name:B
Last Name:BRYAN
Suffix:JR
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 1:1520 N LEG RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-4332
Mailing Address - Country:US
Mailing Address - Phone:706-869-3121
Mailing Address - Fax:706-869-3126
Practice Address - Street 1:1520 N LEG RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-4332
Practice Address - Country:US
Practice Address - Phone:706-869-3121
Practice Address - Fax:706-869-3126
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032138207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100030OtherBSBS OF GEORGIA
GA52062030OtherBCBS
SCG32138Medicaid
GA10040078OtherAMERIGROUP
GA175227350AMedicaid
SCG32138Medicaid
GA10040078OtherAMERIGROUP