Provider Demographics
NPI:1801007307
Name:DURA MATER, INC
Entity Type:Organization
Organization Name:DURA MATER, INC
Other - Org Name:BRYANT G. GEORGE, SR. M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYANT
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:985-690-0135
Mailing Address - Street 1:700 GAUSE BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2800
Mailing Address - Country:US
Mailing Address - Phone:985-690-0135
Mailing Address - Fax:985-690-0136
Practice Address - Street 1:700 GAUSE BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2800
Practice Address - Country:US
Practice Address - Phone:985-690-0135
Practice Address - Fax:985-690-0136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018940174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1378356Medicaid
LA54896Medicare ID - Type Unspecified
LAD66126Medicare UPIN