Basic Information
| Provider Information | |||||||||
| NPI: | 1902834690 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ARCHER | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 186 TIDEWATER RD | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394027923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012882190 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6051 HIGHWAY 49 | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012887000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 13769 | MS | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00113217 | 05 | MS | MEDICAID |