Basic Information
| Provider Information | |||||||||
| NPI: | 1750379707 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYAN | ||||||||
| FirstName: | PHILLIPS | ||||||||
| MiddleName: | RESPESS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRYAN | ||||||||
| OtherFirstName: | PHILLIPS | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | JR. | ||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 70 MEDICAL CENTER CIR | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | FISHERSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229392273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403325926 | ||||||||
| FaxNumber: | 5403325930 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 MEDICAL CENTER CIR | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | FISHERSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229392273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403325926 | ||||||||
| FaxNumber: | 5403325930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 03/12/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 0101019811 | VA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 011345 | 01 | VA | BCBS ANTHEM | OTHER |