Provider Demographics
NPI:1316967045
Name:POTTER, BRYAN O'NEIL (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:O'NEIL
Last Name:POTTER
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 1:1901 BUTTERFIELD RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-7915
Mailing Address - Country:US
Mailing Address - Phone:630-725-2700
Mailing Address - Fax:
Practice Address - Street 1:2820 CENTRAL AVE STE A
Practice Address - Street 2:SUITE A
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-8624
Practice Address - Country:US
Practice Address - Phone:406-252-8346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25437208600000X
IN01066565A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8413155Medicaid
OR006476Medicaid
IN250520Medicare PIN
WA8413155Medicaid
INP01031455Medicare PIN
OR139424Medicare PIN
WA8868771Medicare PIN
H78696Medicare UPIN
INDF7130Medicare PIN
INM400063283Medicare PIN