Provider Demographics
NPI:1043437684
Name:THE BEACH SURGICAL GROUP
Entity Type:Organization
Organization Name:THE BEACH SURGICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:ANTHONY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-467-1386
Mailing Address - Street 1:PO BOX 2548
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39521-2548
Mailing Address - Country:US
Mailing Address - Phone:228-467-1386
Mailing Address - Fax:228-467-1770
Practice Address - Street 1:952 GREEN MEADOW RD.
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520
Practice Address - Country:US
Practice Address - Phone:228-467-1386
Practice Address - Fax:228-467-1770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2012-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14843261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
1356349401OtherDR'S NPI #
MS9015599Medicaid
MS9015599Medicaid