Provider Demographics
NPI:1073640769
Name:BRYANT FAMILY MEDICAL CLINIC, P.A.
Entity type:Organization
Organization Name:BRYANT FAMILY MEDICAL CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GAELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-804-9712
Mailing Address - Street 1:408 OFFICE PARK DR STE 3
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-7536
Mailing Address - Country:US
Mailing Address - Phone:501-847-2835
Mailing Address - Fax:501-847-6809
Practice Address - Street 1:408 OFFICE PARK DR STE 3
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-7536
Practice Address - Country:US
Practice Address - Phone:501-847-2835
Practice Address - Fax:501-847-6809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC2196261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARMC2196OtherARKANSAS STATE MEDICAL BO
AR5C709Medicare ID - Type Unspecified
ARG78491Medicare UPIN