Provider Demographics
NPI:1851810436
Name:BRYAN, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:BRYAN
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 1:7922 S PAXTON AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-1121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14447 S BENSLEY AVE
Practice Address - Street 2:
Practice Address - City:BURNHAM
Practice Address - State:IL
Practice Address - Zip Code:60633-2224
Practice Address - Country:US
Practice Address - Phone:708-444-1012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator