Healthcare Provider Details

I. General information

NPI: 1083772883
Provider Name (Legal Business Name): BRYANT GERARD GEORGE SR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 03/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 FOSTER ST
LAKE CHARLES LA
70601-5815
US

IV. Provider business mailing address

PO BOX 62600 DEPT 1453
NEW ORLEANS LA
70162-2600
US

V. Phone/Fax

Practice location:
  • Phone: 337-436-7560
  • Fax: 337-433-9861
Mailing address:
  • Phone: 337-436-7560
  • Fax: 337-433-9861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number018940
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: