Basic Information
| Provider Information | |||||||||
| NPI: | 1437576352 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SELF | ||||||||
| FirstName: | BRYANT | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 COLONY LN | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394022369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622138195 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1906 BELLEVIEW AVE SE | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240141838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004228482 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2014 | ||||||||
| LastUpdateDate: | 05/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | 0102204394 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
No ID Information.