Provider Demographics
NPI:1730499948
Name:CYNTHIA BLACKWELL BRYAN MD PA
Entity Type:Organization
Organization Name:CYNTHIA BLACKWELL BRYAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:BLACKWELL
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-897-1700
Mailing Address - Street 1:1001 W. COLLEGE BLVD
Mailing Address - Street 2:SUITE G
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578
Mailing Address - Country:US
Mailing Address - Phone:850-897-1700
Mailing Address - Fax:850-897-1792
Practice Address - Street 1:1001 W. COLLEGE BLVD
Practice Address - Street 2:SUITE G
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578
Practice Address - Country:US
Practice Address - Phone:850-897-1700
Practice Address - Fax:850-897-1792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-21
Last Update Date:2015-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80397207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259143000Medicaid
H180750001Medicare UPIN