Provider Demographics
NPI:1891339305
Name:COBB, BRYCE R III
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:R
Last Name:COBB
Suffix:III
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 1:34025 PINEWOODS CIR APT 103
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-8219
Mailing Address - Country:US
Mailing Address - Phone:313-477-6147
Mailing Address - Fax:
Practice Address - Street 1:34025 PINEWOODS CIR APT 103
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-8219
Practice Address - Country:US
Practice Address - Phone:313-477-6147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist