Basic Information
| Provider Information | |||||||||
| NPI: | 1023060316 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PIERCE | ||||||||
| FirstName: | BRYANT | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2537 MOMENTUM PLACE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606895325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169751845 | ||||||||
| FaxNumber: | 6162850846 | ||||||||
| Practice Location | |||||||||
| Address1: | 1840 WEALTHY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495062921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167747444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 04/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301038089 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207PE0004X | 4301038089 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207L00000X | 4301038089 | MI | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 930080725 | 01 | MI | RAILROAD MEDICARE | OTHER |