Healthcare Provider Details

I. General information

NPI: 1720221252
Provider Name (Legal Business Name): ROOSEVELT BRYANT III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2009
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13400 E SHEA BLVD
SCOTTSDALE AZ
85259-5452
US

IV. Provider business mailing address

13400 E SHEA BLVD
SCOTTSDALE AZ
85259-5499
US

V. Phone/Fax

Practice location:
  • Phone: 480-301-8000
  • Fax:
Mailing address:
  • Phone: 480-301-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number47912
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number35.121454
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number01094181A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number58889
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: