Healthcare Provider Details

I. General information

NPI: 1528270816
Provider Name (Legal Business Name): BRYAN J PRUDHOMME MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MED TECH PKWY STE. 180
JOHNSON CITY TN
37604
US

IV. Provider business mailing address

PO BOX 632476
CINCINNATI OH
45263-2476
US

V. Phone/Fax

Practice location:
  • Phone: 423-794-5540
  • Fax: 423-926-3187
Mailing address:
  • Phone: 423-794-5540
  • Fax: 423-926-3187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number42204
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3000368
Identifier TypeMEDICAID
Identifier StateTN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: