Provider Demographics
NPI:1487679163
Name:BRYANT, R SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:R
Middle Name:SAMUEL
Last Name:BRYANT
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 1:7001 A ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-4205
Mailing Address - Country:US
Mailing Address - Phone:402-484-7001
Mailing Address - Fax:402-484-7006
Practice Address - Street 1:7001 A ST STE 100
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-4205
Practice Address - Country:US
Practice Address - Phone:402-484-7001
Practice Address - Fax:402-484-7006
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17600208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025893600Medicaid
D09095Medicare UPIN
NENA1609001Medicare PIN