Provider Demographics
NPI:1831271758
Name:BRYAN, MICHAEL RICHARD (LPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RICHARD
Last Name:BRYAN
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:SUITE #123
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5937
Practice Address - Country:US
Practice Address - Phone:907-455-4401
Practice Address - Fax:907-455-4402
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK432225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPT0432Medicaid
P27332Medicare UPIN
AK151581Medicare PIN