Basic Information
| Provider Information | |||||||||
| NPI: | 1043437684 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE BEACH SURGICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2548 | ||||||||
| Address2: | |||||||||
| City: | BAY ST LOUIS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395212548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284671386 | ||||||||
| FaxNumber: | 2284671770 | ||||||||
| Practice Location | |||||||||
| Address1: | 952 GREEN MEADOW RD. | ||||||||
| Address2: | |||||||||
| City: | BAY ST LOUIS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284671386 | ||||||||
| FaxNumber: | 2284671770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 07/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | ANTHONY | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2284671386 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 14843 | MS | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1356349401 | 01 | DR'S NPI # | OTHER | 9015599 | 05 | MS | MEDICAID |