Basic Information
| Provider Information | |||||||||
| NPI: | 1821007949 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYANT | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | LANCE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 SAINT CLAIR AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458852400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193001129 | ||||||||
| FaxNumber: | 4193949575 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 S KNOXVILLE AVE STE C | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458852609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193949595 | ||||||||
| FaxNumber: | 4193949532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 04/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 34-005959 | OH | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1184652539 | 01 | OH | GROUP NPI - JTDM FAMILY PRACTICE, LLC | OTHER | 0989097 | 05 | OH | MEDICAID | 34-1689161 | 01 | OH | TAX ID | OTHER | H039441 | 01 | OH | MEDICARE | OTHER |