Provider Demographics
NPI:1447287495
Name:BRYAN, GEORGE T JR (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:T
Last Name:BRYAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5666 EAST STATE STREET
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2472
Mailing Address - Country:US
Mailing Address - Phone:815-226-2000
Mailing Address - Fax:815-227-2658
Practice Address - Street 1:5666 EAST STATE STREET
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2472
Practice Address - Country:US
Practice Address - Phone:815-226-2000
Practice Address - Fax:815-227-2658
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36090851Medicaid
ILL37893Medicare ID - Type Unspecified
ILK48635Medicare PIN
F93761Medicare UPIN
B51813Medicare UPIN