Basic Information
| Provider Information | |||||||||
| NPI: | 1235243023 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRYAN C. DAVIS, M.D., P.A. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAMILY CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1305 E 19TH AVE | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 671565201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202219500 | ||||||||
| FaxNumber: | 6202213700 | ||||||||
| Practice Location | |||||||||
| Address1: | 1305 E 19TH AVE | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 671565201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202219500 | ||||||||
| FaxNumber: | 6202213700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 08/29/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6202219500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 04-27652 | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100327700C | 05 | KS | MEDICAID | 336640 | 01 | KS | FIRSTGUARD | OTHER | 130330 | 01 | KS | BC/BS OF KANSAS | OTHER |