Basic Information
| Provider Information | |||||||||
| NPI: | 1255570263 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWANSON | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000 | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463110800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198642107 | ||||||||
| FaxNumber: | 2198642649 | ||||||||
| Practice Location | |||||||||
| Address1: | 35491 EAGLE WAY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606780001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198642107 | ||||||||
| FaxNumber: | 2198642649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2009 | ||||||||
| LastUpdateDate: | 07/20/2011 | ||||||||
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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 | 207P00000X | 02003447A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200982680 | 05 | IN | MEDICAID |