Provider Demographics
NPI:1598728586
Name:RICHARDSON, BRADY L (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADY
Middle Name:L
Last Name:RICHARDSON
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 1:220 HIGHWAY 12 W
Mailing Address - Street 2:BAPTIST MED CTR KOSCIUSKO
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-3208
Mailing Address - Country:US
Mailing Address - Phone:662-290-3150
Mailing Address - Fax:662-290-3160
Practice Address - Street 1:220 HIGHWAY 12 W
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3208
Practice Address - Country:US
Practice Address - Phone:662-290-3150
Practice Address - Fax:662-290-3160
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18287207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03482344Medicaid
MS080003906Medicare PIN
MSI07585Medicare UPIN