Provider Demographics
NPI:1255570263
Name:SWANSON, BRYAN CHRISTOPHER (DO)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:CHRISTOPHER
Last Name:SWANSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-0800
Mailing Address - Country:US
Mailing Address - Phone:219-864-2107
Mailing Address - Fax:219-864-2649
Practice Address - Street 1:35491 EAGLE WAY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60678-0001
Practice Address - Country:US
Practice Address - Phone:219-864-2107
Practice Address - Fax:219-864-2649
Is Sole Proprietor?:No
Enumeration Date:2009-02-13
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003447A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200982680Medicaid
IN200982680Medicaid