Provider Demographics
NPI:1467549493
Name:BRYAN, MARK (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BRYAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:IL
Mailing Address - Zip Code:61028
Mailing Address - Country:US
Mailing Address - Phone:815-858-9625
Mailing Address - Fax:815-858-9625
Practice Address - Street 1:1763 S DIRCK DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6707
Practice Address - Country:US
Practice Address - Phone:815-233-5100
Practice Address - Fax:815-235-2233
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist