Provider Demographics
NPI:1811148802
Name:MICHAEL D. BRYAN, MD
Entity type:Organization
Organization Name:MICHAEL D. BRYAN, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DENNIS
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-416-9731
Mailing Address - Street 1:660 W SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6069
Mailing Address - Country:US
Mailing Address - Phone:817-416-9731
Mailing Address - Fax:817-416-9751
Practice Address - Street 1:660 W SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6069
Practice Address - Country:US
Practice Address - Phone:817-416-9731
Practice Address - Fax:817-416-9751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1503207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0059ADMedicare PIN
G33200Medicare UPIN