Healthcare Provider Details

I. General information

NPI: 1255570263
Provider Name (Legal Business Name): BRYAN CHRISTOPHER SWANSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2009
Last Update Date: 07/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35491 EAGLE WAY
CHICAGO IL
60678-0001
US

IV. Provider business mailing address

PO BOX 1000
DYER IN
46311-0800
US

V. Phone/Fax

Practice location:
  • Phone: 219-864-2107
  • Fax: 219-864-2649
Mailing address:
  • Phone: 219-864-2107
  • Fax: 219-864-2649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number02003447A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: