Basic Information
| Provider Information | |||||||||
| NPI: | 1932185626 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLITSTEIN | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 33369 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282333369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043648100 | ||||||||
| FaxNumber: | 7043652073 | ||||||||
| Practice Location | |||||||||
| Address1: | 10030 GILEAD RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | HUNTERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280787545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048959390 | ||||||||
| FaxNumber: | 7044645948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 02/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 97-00865 | NC | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 9700865 | NC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 8910672 | 05 | NC | MEDICAID |