Healthcare Provider Details

I. General information

NPI: 1194952861
Provider Name (Legal Business Name): BRYCE CALLISTER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2009
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 S PARKSIDE DRIVE
COLORADO SPRINGS CO
80910
US

IV. Provider business mailing address

220 RUSKIN DRIVE
COLORADO SPRINGS CO
80910
US

V. Phone/Fax

Practice location:
  • Phone: 719-572-6100
  • Fax: 719-447-4740
Mailing address:
  • Phone: 719-572-6100
  • Fax: 719-447-4792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDR.0053429
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberOT012962
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: