Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | 5987 | SD |
NPI | 1003815804 |
---|---|
Provider Name | Keith G Bryson |
First Address | Rapid City, SD 57701-6000 |
Second Address | Rapid City, SD 57701-6003 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2005 |
Last Update Date | 06/02/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C81551 | (02) | |
P00414306 | RR MEDICARE (01) | SD |