Healthcare Provider Details

I. General information

NPI: 1104811512
Provider Name (Legal Business Name): KEVIN PATRICK BRYAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 SUN N LAKE BLVD
SEBRING FL
33872-1986
US

IV. Provider business mailing address

4200 SUN N LAKE BLVD
SEBRING FL
33872-1986
US

V. Phone/Fax

Practice location:
  • Phone: 407-975-0412
  • Fax: 407-975-0407
Mailing address:
  • Phone: 407-975-0412
  • Fax: 407-975-0407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD417302
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME121818
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME121818
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: