Healthcare Provider Details

I. General information

NPI: 1255593265
Provider Name (Legal Business Name): BLAINE COOPER BRITT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 05/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 BROOKWAY BLVD
BROOKHAVEN MS
39601-2644
US

IV. Provider business mailing address

950 BROOKWAY BLVD
BROOKHAVEN MS
39601-2644
US

V. Phone/Fax

Practice location:
  • Phone: 601-833-7973
  • Fax: 601-823-3514
Mailing address:
  • Phone: 601-833-7973
  • Fax: 601-823-3514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number30508
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number30508
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number22176
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22176
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: