Provider Demographics
NPI:1194975128
Name:BRYANT, BENJAMIN J (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:J
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 1:8050 ROEPKE CT
Mailing Address - Street 2:
Mailing Address - City:GREGORY
Mailing Address - State:MI
Mailing Address - Zip Code:48137-9645
Mailing Address - Country:US
Mailing Address - Phone:440-265-9034
Mailing Address - Fax:
Practice Address - Street 1:8050 ROEPKE CT
Practice Address - Street 2:
Practice Address - City:GREGORY
Practice Address - State:MI
Practice Address - Zip Code:48137-9645
Practice Address - Country:US
Practice Address - Phone:440-265-9034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301055735208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2882386Medicaid
OH4247421Medicare PIN