Basic Information
| Provider Information | |||||||||
| NPI: | 1124097167 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FRY | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | BRIAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 260 FORT SANDERS WEST BLVD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379223355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657694500 | ||||||||
| FaxNumber: | 8657694557 | ||||||||
| Practice Location | |||||||||
| Address1: | 260 FORT SANDERS WEST BLVD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379223355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655584400 | ||||||||
| FaxNumber: | 8657694536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 06/20/2017 | ||||||||
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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 | 2081P2900X | DO1406 | TN | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208100000X | DO1406 | TN | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | TN01B1 | 01 | TN | JOHN DEERE HEALTHCARE | OTHER | 3306949 | 05 | TN | MEDICAID | 4028311 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER | TN01A9 | 01 | TN | JOHN DEERE HEALTHCARE | OTHER | 250014223 | 01 | TN | RAILROAD MEDICARE | OTHER | 2340066 | 01 | TN | UNITED HEALTH CARE | OTHER |