Provider Demographics
NPI:1659558591
Name:BRYAN R CONKLIN MD PC
Entity Type:Organization
Organization Name:BRYAN R CONKLIN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CONKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD PC
Authorized Official - Phone:541-963-4139
Mailing Address - Street 1:2011 FOURTH STREET
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-1200
Mailing Address - Country:US
Mailing Address - Phone:541-963-4139
Mailing Address - Fax:541-963-4412
Practice Address - Street 1:2011 FOURTH STREET
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1200
Practice Address - Country:US
Practice Address - Phone:541-963-4139
Practice Address - Fax:541-963-4412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23049207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR228792Medicaid
ORR117125Medicare PIN
OR228792Medicaid