Provider Demographics
NPI:1679641450
Name:ANTHONY, MICHAEL DREW (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DREW
Last Name:ANTHONY
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 1:100 BRANDON RD
Mailing Address - Street 2:SUITE S
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-2571
Mailing Address - Country:US
Mailing Address - Phone:662-320-3990
Mailing Address - Fax:
Practice Address - Street 1:100 BRANDON RD
Practice Address - Street 2:SUITE S
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-2571
Practice Address - Country:US
Practice Address - Phone:662-320-3990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17126208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126022Medicaid
H27726Medicare UPIN
MS80003610Medicare PIN