Provider Demographics
NPI:1770240350
Name:WILLIAMS, BRYANT KEITH
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:KEITH
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10013 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60131-2546
Mailing Address - Country:US
Mailing Address - Phone:847-681-7704
Mailing Address - Fax:
Practice Address - Street 1:10013 GRAND AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN PARK
Practice Address - State:IL
Practice Address - Zip Code:60131-2546
Practice Address - Country:US
Practice Address - Phone:847-681-7704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist