Provider Demographics
NPI:1518963511
Name:BRYAN, ALPHA FOWLER (MD)
Entity Type:Individual
Prefix:MRS
First Name:ALPHA
Middle Name:FOWLER
Last Name:BRYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 COUNTY SERVICES PKWY SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30008-4010
Mailing Address - Country:US
Mailing Address - Phone:770-514-2361
Mailing Address - Fax:770-514-2811
Practice Address - Street 1:1650 COUNTY SERVICES PKWY SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30008-4010
Practice Address - Country:US
Practice Address - Phone:770-514-2361
Practice Address - Fax:770-514-2811
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA35733207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00908454AMedicaid
GA08BBVJMMedicare ID - Type Unspecified
GA00908454AMedicaid