Provider Demographics
NPI:1639327224
Name:BRAND PROFESSIONAL SERVICES INC
Entity Type:Organization
Organization Name:BRAND PROFESSIONAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LAMAR
Authorized Official - Last Name:BRAND
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:229-724-8823
Mailing Address - Street 1:PO BOX 593
Mailing Address - Street 2:
Mailing Address - City:COLQUITT
Mailing Address - State:GA
Mailing Address - Zip Code:39837-0593
Mailing Address - Country:US
Mailing Address - Phone:229-725-4272
Mailing Address - Fax:949-955-5482
Practice Address - Street 1:208 N CUTHBERT ST
Practice Address - Street 2:
Practice Address - City:COLQUITT
Practice Address - State:GA
Practice Address - Zip Code:39837-3517
Practice Address - Country:US
Practice Address - Phone:229-758-3304
Practice Address - Fax:949-955-5482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2010-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046045207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000820322DMedicaid
GAG80070Medicare UPIN
GA000820322DMedicaid