Basic Information
| Provider Information | |||||||||
| NPI: | 1639170491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEPHENS | ||||||||
| FirstName: | BRYON | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6920 POINTE INVERNESS WAY STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604793514 | ||||||||
| FaxNumber: | 2604793520 | ||||||||
| Practice Location | |||||||||
| Address1: | 7910 W JEFFERSON BLVD | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609697121 | ||||||||
| FaxNumber: | 2604364292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 01040106A | IN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0998112 | 05 | OH | MEDICAID | 100082280 | 05 | IN | MEDICAID | 103410227 | 05 | MI | MEDICAID | P00919721 | 01 | IN | RAILROAD MEDICARE | OTHER |