Provider Demographics
NPI:1962419663
Name:BRYANT, MARY M (MD)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:M
Last Name:BRYANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4002 KRESGE WAY
Mailing Address - Street 2:#100
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207
Mailing Address - Country:US
Mailing Address - Phone:502-897-1121
Mailing Address - Fax:502-897-1189
Practice Address - Street 1:4002 KRESGE WAY
Practice Address - Street 2:#100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207
Practice Address - Country:US
Practice Address - Phone:502-897-1121
Practice Address - Fax:502-897-1189
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30713207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000051875OtherANTHEM
KY64307135Medicaid
110165641OtherRR
KYBB4116427OtherDEA
110165641OtherRR
KY0523103Medicare ID - Type Unspecified