Individual
KENNETH LANCE BRYANT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
1140 S KNOXVILLE AVE STE C, SAINT MARYS, OH 45885-2609
(419) 394-9595
(419) 394-9532
Mailing address
200 SAINT CLAIR AVE, SAINT MARYS, OH 45885-2400
(419) 300-1129
(419) 394-9575
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
34-005959
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0989097
—
OH
01
—
1184652539
GROUP NPI - JTDM FAMILY PRACTICE, LLC
OH
01
—
34-1689161
TAX ID
OH
01
—
H039441
MEDICARE
OH
Enumeration date
08/07/2006
Last updated
04/19/2021
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