1609842947 NPI number — SUSAN J BRYANT MD

Table of content: SUSAN J BRYANT MD (NPI 1609842947)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609842947 NPI number — SUSAN J BRYANT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRYANT
Provider First Name:
SUSAN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRYANT
Provider Other First Name:
SUSAN
Provider Other Middle Name:
JEANINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609842947
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29301 N DIXIE RANCH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LACOMBE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-871-4114
Provider Business Mailing Address Fax Number:
985-871-4130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3434 HOUMA BLVD STE 301
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
METAIRIE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70006-4201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-635-2601
Provider Business Practice Location Address Fax Number:
504-324-2078
Provider Enumeration Date:
02/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X , with the licence number:  021783 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0000X , with the licence number: 021783 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1691496 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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