Basic Information
| Provider Information | |||||||||
| NPI: | 1679528798 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRYAN PHYSICIAN NETWORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 S 16TH ST | ||||||||
| Address2: | SUITE 400A | ||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685023796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024838590 | ||||||||
| FaxNumber: | 4024838599 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 S 16TH ST | ||||||||
| Address2: | SUITE 400A | ||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685023796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024838590 | ||||||||
| FaxNumber: | 4024838599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | MOOSS | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4024815603 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VM0101X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 2080N0001X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2084N0400X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084P0800X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208600000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 2086S0122X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10025136400 | 05 | NE | MEDICAID | 10025481300 | 05 | NE | MEDICAID | 10025896400 | 05 | NE | MEDICAID | 10026311700 | 05 | NE | MEDICAID | 10026454500 | 05 | NE | MEDICAID | 10026464400 | 05 | NE | MEDICAID | 10025392200 | 05 | NE | MEDICAID | 10025636100 | 05 | NE | MEDICAID | 10025718000 | 05 | NE | MEDICAID | 10026416000 | 05 | NE | MEDICAID | 10026418100 | 05 | NE | MEDICAID | 10025382000 | 05 | NE | MEDICAID |