MEDICARE: DR. GARY MICHAEL BRIDEN D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	036-068930	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	834340	OTHER	IL	MEDICARE GROUP #

General Provider Information

NPI Number	:	1710965439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY MICHAEL BRIDEN D.O.

Provider Business Mailing Address
First Line	:	9388 STEEPLEBUSH DR
Second Line	:
City	:	BELVIDERE
State	:	IL
Zip	:	61008-7120
Country	:	US
Telephone Number	:	815-332-1785
Fax Number	:

Provider Business Practice Location Address
First Line	:	4423 MANCHESTER DR
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61109-1655
Country	:	US
Telephone Number	:	815-394-1391
Fax Number	:	815-226-0114

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2006
Last Update Date	:	01/30/2009

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