Provider Demographics
NPI:1396909446
Name:BRYANT STREET FAMILY MEDICINE, P.C.
Entity type:Organization
Organization Name:BRYANT STREET FAMILY MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHESCA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:CRAIG-GOODELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:405-513-7333
Mailing Address - Street 1:305 SOUTH BRYANT AVE
Mailing Address - Street 2:110
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034
Mailing Address - Country:US
Mailing Address - Phone:405-513-7333
Mailing Address - Fax:405-513-7337
Practice Address - Street 1:305 SOUTH BRYANT AVE
Practice Address - Street 2:110
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034
Practice Address - Country:US
Practice Address - Phone:405-513-7333
Practice Address - Fax:405-513-7337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-17
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1366510802OtherINDIVIDUAL PROVIDER NPI NUMBER