Provider Demographics
NPI:1356349401
Name:ANTHONY, BRIAN THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:THOMAS
Last Name:ANTHONY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-575-1194
Mailing Address - Fax:228-575-2917
Practice Address - Street 1:833 HIGHWAY 90 STE 1
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-1601
Practice Address - Country:US
Practice Address - Phone:228-575-2920
Practice Address - Fax:228-466-4677
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS14843208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015599OtherGROUP MEDICAID NUMBER: TAX ID 64-093424
MT00116990Medicaid
MS09015599OtherGROUP MEDICAID NUMBER: TAX ID 64-093424
MSE98669Medicare UPIN