Healthcare Provider Details

I. General information

NPI: 1356349401
Provider Name (Legal Business Name): BRIAN THOMAS ANTHONY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 HIGHWAY 90 STE 1
BAY ST LOUIS MS
39520-1601
US

IV. Provider business mailing address

PO BOX 1810
GULFPORT MS
39502-1810
US

V. Phone/Fax

Practice location:
  • Phone: 228-575-2920
  • Fax: 228-466-4677
Mailing address:
  • Phone: 228-575-1194
  • Fax: 228-575-2917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number14843
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: