Healthcare Provider Details

I. General information

NPI: 1538137930
Provider Name (Legal Business Name): BRICE STEELE ROLSTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 11/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71107 HIGHWAY 21 SUITE 3
COVINGTON LA
70433-7151
US

IV. Provider business mailing address

187 GREENBRIAR BLVD SUITE A
COVINGTON LA
70433-7234
US

V. Phone/Fax

Practice location:
  • Phone: 985-893-5780
  • Fax: 985-893-0601
Mailing address:
  • Phone: 985-893-5780
  • Fax: 985-893-0601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number12914
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: