Basic Information
| Provider Information | |||||||||
| NPI: | 1124261185 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRYANT J. BROWN, M.D., A PROFESSIONAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3970 S 700 E | ||||||||
| Address2: | SUITE 14 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841072191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012613605 | ||||||||
| FaxNumber: | 8012629142 | ||||||||
| Practice Location | |||||||||
| Address1: | 3970 S 700 E | ||||||||
| Address2: | SUITE 14 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841072191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012613605 | ||||||||
| FaxNumber: | 8012629142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2009 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | BRYANT | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8012613605 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 1579931205 | VI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 528682716004 | 05 | UT | MEDICAID |