Basic Information
| Provider Information | |||||||||
| NPI: | 1326042037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARDY | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | HOLLAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 612 S 12TH ST | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729014702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797852431 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1301 S E ST | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729014716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797852431 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 04/14/2017 | ||||||||
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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 | 207Q00000X | E-2745 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7848374 | 01 | AETNA | OTHER | BC7116418 | 01 | AR | DEA NUMBER | OTHER | 100143000A | 05 | OK | MEDICAID | 1637041 | 05 | LA | MEDICAID | 2220866 | 01 | AR | UNITED HEALTHCARE | OTHER | 2674666001 | 01 | CIGNA | OTHER | 5M245 | 01 | AR | BLUE CROSS/BLUE SHIELD | OTHER | 02090005200 | 01 | QUALCHOICE | OTHER | 02450298 | 05 | MS | MEDICAID | 146720001 | 05 | AR | MEDICAID | 080184879 | 01 | RAILROAD MEDICARE | OTHER |