Basic Information
Provider Information | |||||||||
NPI: | 1033170683 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PIEDAD | ||||||||
FirstName: | BRYAN | ||||||||
MiddleName: | T. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 55 WHITCHER ST NE | ||||||||
Address2: | SUITE 350 | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300601155 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704246893 | ||||||||
FaxNumber: | 7705289938 | ||||||||
Practice Location | |||||||||
Address1: | 55 WHITCHER ST NE | ||||||||
Address2: | SUITE 350 | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300601155 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704246893 | ||||||||
FaxNumber: | 7705289938 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2006 | ||||||||
LastUpdateDate: | 11/25/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207UN0902X | 55779 | GA | N |   | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Imaging & Therapy | 207RC0001X | 55779 | GA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0000X | 55779 | GA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207UN0901X | 55779 | GA | N |   | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology |
ID Information
ID | Type | State | Issuer | Description | 258441706S | 05 | GA |   | MEDICAID | 258441706Q | 05 | GA |   | MEDICAID | 258441706P | 05 | GA |   | MEDICAID | 258441706R | 05 | GA |   | MEDICAID | 258441706T | 05 | GA |   | MEDICAID |