Basic Information
| Provider Information | |||||||||
| NPI: | 1548586118 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 200 3RD AVE W | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342058626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417920340 | ||||||||
| FaxNumber: | 9417942251 | ||||||||
| Practice Location | |||||||||
| Address1: | 2234 COLONIAL BLVD | ||||||||
| Address2: | ATTN: PAYER CONTRACTING & RELATIONS | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399317342 | ||||||||
| FaxNumber: | 2399317385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2010 | ||||||||
| LastUpdateDate: | 03/16/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208800000X | ME120341 | FL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 1192921 | 01 | FL | WELLCARE | OTHER | P1033007 | 01 | FL | FREEDOM | OTHER | P01796855 | 01 | FL | CLEAR HEALTH ALLIANCE | OTHER | 150JQ | 01 | FL | BCBS | OTHER | 9438549 | 01 | FL | CIGNA | OTHER | P01520110 | 01 | FL | RAILROAD MEDICARE | OTHER | P969301 | 01 | FL | OPTIMUM | OTHER | 015011500 | 05 | FL | MEDICAID | 4840869 | 01 | FL | AETNA | OTHER |