Provider Demographics
NPI:1639243983
Name:SMITH, BRYAN LEONARD (MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:LEONARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 947407
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-7407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:200 HEALTHCARE WAY
Practice Address - Street 2:
Practice Address - City:NORTH VENICE
Practice Address - State:FL
Practice Address - Zip Code:34275-3669
Practice Address - Country:US
Practice Address - Phone:941-261-2000
Practice Address - Fax:941-261-0880
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58340208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020012690OtherRAILROAD MEDICARE
FL303424OtherUNITED HEALTH CARE GROUP
FL4890OtherUNIVERSAL HEALTH CARE
FL59-13692995OtherGROUP TAX IDENTIFICATION
FL10775OtherBCBS
FL3323218OtherCIGNA
FL04890OtherUNIVERSAL
FL00778OtherBLUE CROSS BLUE SHIELD GROUP
FL303424OtherUNITED HEALTH CARE GROUP
FL10775ZMedicare ID - Type Unspecified
FLC78649Medicare UPIN