1467930537 NPI number — MICHAEL ANTHONY MCBRYDE PT, DPT

Table of content: MICHAEL ANTHONY MCBRYDE PT, DPT (NPI 1467930537)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467930537 NPI number — MICHAEL ANTHONY MCBRYDE PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCBRYDE
Provider First Name:
MICHAEL
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467930537
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANTACHIE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38855-0205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-282-4949
Provider Business Mailing Address Fax Number:
662-282-4955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
230 MAIN ST.
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
NETTLETON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-591-7077
Provider Business Practice Location Address Fax Number:
662-591-7078
Provider Enumeration Date:
08/01/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT6462 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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