Healthcare Provider Details

I. General information

NPI: 1356874598
Provider Name (Legal Business Name): ELENA V BRYANT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 09/23/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 4TH ST
BRUNSWICK GA
31520-3779
US

IV. Provider business mailing address

3300 4TH ST
BRUNSWICK GA
31520-3779
US

V. Phone/Fax

Practice location:
  • Phone: 912-466-5870
  • Fax:
Mailing address:
  • Phone: 912-466-5870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number85652
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: