Provider Demographics
NPI:1861506792
Name:HUMPHERYS, BRIAN E (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:E
Last Name:HUMPHERYS
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5630
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:7148 HWY 98 WEST
Practice Address - Street 2:SUITE 203
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402
Practice Address - Country:US
Practice Address - Phone:601-268-5630
Practice Address - Fax:601-579-5240
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17658207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125863Medicaid
LA1758167Medicaid
MS2292722OtherAMERICAN ADMIN GROUP
MS2292722OtherAMERICAN ADMIN GROUP
MS200044547OtherRAILROAD MEDICARE
H54200Medicare UPIN