Healthcare Provider Details

I. General information

NPI: 1760627996
Provider Name (Legal Business Name): GLENN ANTHONY BRIEN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2008
Last Update Date: 09/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 BURNEY DR
FLOWOOD MS
39232-6621
US

IV. Provider business mailing address

PO BOX 30594
CHARLOTTE NC
28230-0594
US

V. Phone/Fax

Practice location:
  • Phone: 601-987-8200
  • Fax: 601-987-8211
Mailing address:
  • Phone: 601-987-8200
  • Fax: 601-987-8211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberM9881
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: