Provider Demographics
NPI:1194995696
Name:EDWIN D BRYAN INC
Entity type:Organization
Organization Name:EDWIN D BRYAN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:251-929-3191
Mailing Address - Street 1:12930 MARY ANN BEACH RD
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-5423
Mailing Address - Country:US
Mailing Address - Phone:251-929-3191
Mailing Address - Fax:
Practice Address - Street 1:701 MCMEANS AVE
Practice Address - Street 2:
Practice Address - City:BAY MINETTE
Practice Address - State:AL
Practice Address - Zip Code:36507-3337
Practice Address - Country:US
Practice Address - Phone:251-937-1397
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-490-TA-140305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL5152800OtherBCBS