MEDICARE: BRYAN S. JICK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	G55140	CA

General Provider Information

NPI Number	:	1720051436
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYAN S. JICK MD

Provider Business Mailing Address
First Line	:	625 S FAIR OAKS AVE
Second Line	:	SUITE 255
City	:	PASADENA
State	:	CA
Zip	:	91105-2613
Country	:	US
Telephone Number	:	626-304-2626
Fax Number	:	626-585-0695

Provider Business Practice Location Address
First Line	:	625 S FAIR OAKS AVE
Second Line	:	SUITE 255
City	:	PASADENA
State	:	CA
Zip	:	91105-2613
Country	:	US
Telephone Number	:	626-304-2626
Fax Number	:	626-585-0695

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/12/2006
Last Update Date	:	02/02/2022

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