Provider Demographics
NPI:1841299161
Name:MCHARDY, BRYSON ROY JR (MD,)
Entity type:Individual
Prefix:
First Name:BRYSON
Middle Name:ROY
Last Name:MCHARDY
Suffix:JR
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 1:100 MEDICAL DR
Mailing Address - Street 2:P.O. BOX 311
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-6877
Mailing Address - Country:US
Mailing Address - Phone:573-231-3106
Mailing Address - Fax:573-231-3723
Practice Address - Street 1:100 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6877
Practice Address - Country:US
Practice Address - Phone:573-231-3106
Practice Address - Fax:573-231-3723
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080075252080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01308626Medicaid
COA10238Medicare UPIN
CO01308626Medicaid