Provider Demographics
NPI:1982750881
Name:BRYANT, EVERETT (MD)
Entity Type:Individual
Prefix:DR
First Name:EVERETT
Middle Name:
Last Name:BRYANT
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 1:4241 MAPLE ST
Mailing Address - Street 2:SUITE 200D
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3826
Mailing Address - Country:US
Mailing Address - Phone:313-584-1940
Mailing Address - Fax:313-584-1945
Practice Address - Street 1:4241 MAPLE ST
Practice Address - Street 2:SUITE 200D
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3826
Practice Address - Country:US
Practice Address - Phone:313-584-1940
Practice Address - Fax:313-584-1945
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIEB060301207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4364049Medicaid
MI0806349462OtherBCBSM
MI4364049Medicaid
MI371428815OtherEIN
MI4364049Medicaid
MIH50492Medicare UPIN