Provider Demographics
NPI:1588686794
Name:BRYANT, GLENN ALLEN III (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:ALLEN
Last Name:BRYANT
Suffix:III
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 1:1001 BELLEFONTAINE AVE
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2800
Mailing Address - Country:US
Mailing Address - Phone:419-998-4575
Mailing Address - Fax:419-998-4586
Practice Address - Street 1:525 N EASTOWN RD STE 102
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45807-2268
Practice Address - Country:US
Practice Address - Phone:419-998-8214
Practice Address - Fax:419-998-8298
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.069135207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2333504Medicaid
OH4084044Medicare PIN
OH2333504Medicaid