Healthcare Provider Details

I. General information

NPI: 1497794010
Provider Name (Legal Business Name): BRYON WESLEY THOMAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S MAIN ST SUITE 212
MISHAWAKA IN
46544-2189
US

IV. Provider business mailing address

303 S MAIN ST SUITE 212
MISHAWAKA IN
46544-2189
US

V. Phone/Fax

Practice location:
  • Phone: 574-254-0800
  • Fax: 574-254-0812
Mailing address:
  • Phone: 574-254-0800
  • Fax: 574-254-0812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01052749
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: