Healthcare Provider Details

I. General information

NPI: 1720247299
Provider Name (Legal Business Name): BRYAN RONALD EADIE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GENESYS PARKWAY GENESYS REGIONAL MEDICAL CENTER
GRAND BLANC MI
48439
US

IV. Provider business mailing address

7 N SQUIRREL RD
AUBURN HILLS MI
48326-4002
US

V. Phone/Fax

Practice location:
  • Phone: 810-606-5000
  • Fax:
Mailing address:
  • Phone: 616-402-7806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101017658
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: