Basic Information
| Provider Information | |||||||||
| NPI: | 1033345251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BINGHAM | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | BRYAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PMHCNS-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3355 GLENDALE AVE FL 3 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436142426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193833780 | ||||||||
| FaxNumber: | 4193833338 | ||||||||
| Practice Location | |||||||||
| Address1: | 3125 TRANSVERSE DR | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436148008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193833780 | ||||||||
| FaxNumber: | 4193833338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2009 | ||||||||
| LastUpdateDate: | 02/08/2018 | ||||||||
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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 | 364SP0809X | RX10719-EX1 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult |
ID Information
| ID | Type | State | Issuer | Description | 2959777 | 05 | OH | MEDICAID |