Healthcare Provider Details

I. General information

NPI: 1992064026
Provider Name (Legal Business Name): GEORGE WAYNE BYRAM III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2012
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 E BERT KOUNS INDUSTRIAL LOOP # 210
SHREVEPORT LA
71105
US

IV. Provider business mailing address

1455 E BERT KOUNS INDUSTRIAL LOOP # 210
SHREVEPORT LA
71105-6000
US

V. Phone/Fax

Practice location:
  • Phone: 187-984-6233
  • Fax:
Mailing address:
  • Phone: 318-423-4482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number24984
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD.308290
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: