Provider Demographics
NPI:1972772051
Name:L R BRYANT MEDICAL CORP
Entity Type:Organization
Organization Name:L R BRYANT MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-689-2525
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:WA
Mailing Address - Zip Code:98812-0098
Mailing Address - Country:US
Mailing Address - Phone:509-689-2525
Mailing Address - Fax:509-689-3247
Practice Address - Street 1:520 W. INDIAN AVENUE
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:WA
Practice Address - Zip Code:98812
Practice Address - Country:US
Practice Address - Phone:509-689-2525
Practice Address - Fax:509-689-3247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00026120207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1115732Medicaid
WA1115732Medicaid