Provider Demographics
NPI:1376519769
Name:BEVERLY, BRIAN K (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:K
Last Name:BEVERLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1059
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799-1059
Mailing Address - Country:US
Mailing Address - Phone:229-226-1200
Mailing Address - Fax:229-226-4522
Practice Address - Street 1:900 GORDON AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6613
Practice Address - Country:US
Practice Address - Phone:229-226-1200
Practice Address - Fax:229-226-4522
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035375207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA110058407OtherRAILROAD MEDICARE
GA000495008AOtherPEACH STATE
GA000495008AMedicaid
GA336160OtherWELLCARE
GA000495008AMedicaid
GA000495008AOtherPEACH STATE