Basic Information
| Provider Information | |||||||||
| NPI: | 1598728586 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | BRADY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 HIGHWAY 12 W | ||||||||
| Address2: | BAPTIST MED CTR KOSCIUSKO | ||||||||
| City: | KOSCIUSKO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390903208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622903150 | ||||||||
| FaxNumber: | 6622903160 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 HIGHWAY 12 W | ||||||||
| Address2: | |||||||||
| City: | KOSCIUSKO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390903208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622903150 | ||||||||
| FaxNumber: | 6622903160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 07/24/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 18287 | MS | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 18287 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03482344 | 05 | MS | MEDICAID |