Provider Demographics
NPI:1144481656
Name:TEPPER, BRYAN KENNETH (DO)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:KENNETH
Last Name:TEPPER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MINERAL POINT AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2940
Mailing Address - Country:US
Mailing Address - Phone:608-756-6611
Mailing Address - Fax:608-756-6177
Practice Address - Street 1:1000 MINERAL POINT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2940
Practice Address - Country:US
Practice Address - Phone:608-756-6611
Practice Address - Fax:608-756-6177
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55572-21207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WITEPPEBRYOtherMERCYCARE INSURANCE
WI1144481656OtherBCBSWI
WI1144481656Medicaid
WI1144481656OtherBCBSWI
WI1144481656OtherBCBSWI