Provider Demographics
NPI:1245472430
Name:CHILD, BRYAN SCOTT (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:SCOTT
Last Name:CHILD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22762 SW 106TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7385
Mailing Address - Country:US
Mailing Address - Phone:509-987-6774
Mailing Address - Fax:
Practice Address - Street 1:890 OAK ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3905
Practice Address - Country:US
Practice Address - Phone:509-987-6774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60279400208000000X, 208M00000X
ORMD184925208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1245472430Medicaid
WA025904OtherKRMC L&I GROUP NUMBER
WA1245472430Medicaid