Provider Demographics
NPI:1770917353
Name:PHILIP C BRYAN MD PLLC
Entity type:Organization
Organization Name:PHILIP C BRYAN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-340-2346
Mailing Address - Street 1:1515 TOWER DR
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-6181
Mailing Address - Country:US
Mailing Address - Phone:405-310-0836
Mailing Address - Fax:405-758-5582
Practice Address - Street 1:1000 N LEE AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-1036
Practice Address - Country:US
Practice Address - Phone:405-272-4200
Practice Address - Fax:405-272-4203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-30
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9273208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200509640AMedicaid
OK505101907Medicaid