Basic Information
| Provider Information | |||||||||
| NPI: | 1881989119 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JARVIS | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 571 SAINT JOSEPHS BLVD | ||||||||
| Address2: | FL 2 | ||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149013230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072712050 | ||||||||
| FaxNumber: | 6078731244 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 JOHN ROEMMELT DR | ||||||||
| Address2: | 102 | ||||||||
| City: | HORSEHEADS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148458301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077951666 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2011 | ||||||||
| LastUpdateDate: | 10/13/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | OT014339 | PA | N | Allopathic & Osteopathic Physicians | General Practice | 207X00000X | 282240 | NY | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 04403343 | 05 | NY | MEDICAID |