Provider Demographics
NPI:1992111025
Name:MICHAEL BRYAN, MD FACOG PLLC
Entity type:Organization
Organization Name:MICHAEL BRYAN, MD FACOG PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CONRAD
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-256-4527
Mailing Address - Street 1:5310 W THUNDERBIRD RD STE 308
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4710
Mailing Address - Country:US
Mailing Address - Phone:623-412-2229
Mailing Address - Fax:602-314-5843
Practice Address - Street 1:5310 W THUNDERBIRD RD STE 308
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4710
Practice Address - Country:US
Practice Address - Phone:623-412-2229
Practice Address - Fax:602-314-5843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37126207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ411665Medicaid
AZ411665Medicaid