Healthcare Provider Details

I. General information

NPI: 1104877265
Provider Name (Legal Business Name): JACK BRYANT ANON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2006
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 W 8TH ST
ERIE PA
16505-5007
US

IV. Provider business mailing address

1645 W 8TH ST
ERIE PA
16505-5007
US

V. Phone/Fax

Practice location:
  • Phone: 814-864-9994
  • Fax: 814-866-2655
Mailing address:
  • Phone: 814-864-9994
  • Fax: 814-866-2655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License NumberMD035571E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: