Provider Demographics
NPI:1962574111
Name:BRYAN A PICOU ET AL PTR
Entity type:Organization
Organization Name:BRYAN A PICOU ET AL PTR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:PICOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-352-2971
Mailing Address - Street 1:740 KEYSER AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-6037
Mailing Address - Country:US
Mailing Address - Phone:318-352-2971
Mailing Address - Fax:
Practice Address - Street 1:740 KEYSER AVE
Practice Address - Street 2:SUITE A
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-6037
Practice Address - Country:US
Practice Address - Phone:318-352-2971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1001236Medicaid
LA1001236Medicaid
LA5C977Medicare PIN