Basic Information
| Provider Information | |||||||||
| NPI: | 1821033093 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRYAN | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | KERR | ||||||||
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| Credential: | MS,PT, CHT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 BOULDERS PKWY | ||||||||
| Address2: | STE 200 | ||||||||
| City: | NORTH CHESTERFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232254067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8049154602 | ||||||||
| FaxNumber: | 8043278496 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 HIOAKS RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232254061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8043308165 | ||||||||
| FaxNumber: | 8043305829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 05/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305001814 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 194769 | 01 | VA | ANTHEM CHIPPENHAM OT | OTHER | 010067286 | 05 | VA | MEDICAID | 258462 | 01 | VA | SOUTHERN HEALTH | OTHER | 98999 | 01 | VA | OPTIMA HEALTH | OTHER |