Healthcare Provider Details

I. General information

NPI: 1427463280
Provider Name (Legal Business Name): BRYAN P. PAYNE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 COURT DR STE 450
GASTONIA NC
28054
US

IV. Provider business mailing address

PO BOX 744786
ATLANTA GA
30374-4786
US

V. Phone/Fax

Practice location:
  • Phone: 704-671-7652
  • Fax: 704-671-7656
Mailing address:
  • Phone: 704-834-2450
  • Fax: 704-671-5331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number5101021272
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2019-00926
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: