Basic Information
| Provider Information | |||||||||
| NPI: | 1629259478 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'BRYAN | ||||||||
| FirstName: | GERALD | ||||||||
| MiddleName: | KANE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3650 LOYOLA DR APT 108 | ||||||||
| Address2: | |||||||||
| City: | KENNER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700655431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044678771 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1990 INDUSTRIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703637055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858689300 | ||||||||
| FaxNumber: | 9858510053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2007 | ||||||||
| LastUpdateDate: | 10/10/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 201218 | LA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 201218 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1073806 | 05 | LA | MEDICAID |