=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942507678
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYAN GLENN WILLIAMS II
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2011
-----------------------------------------------------
Last Update Date | 02/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 208 SHEFFIELD ST
-----------------------------------------------------
City | PHILIPSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16866-1848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-230-3885
-----------------------------------------------------
Fax | 402-505-9753
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 208 SHEFFIELD ST
-----------------------------------------------------
City | PHILIPSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16866-1848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | TE008905
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------