Individual
TERRY KEITH BRANTLEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1850 CHADWICK DR, JACKSON, MS 39204-3404
(904) 805-1300
(904) 805-1302
Mailing address
200 CORPORATE BLVD, STE 201, LAFAYETTE, LA 70508-3870
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
05961
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00014917
—
MS
01
—
P00205130
RAILROAD MEDICARE
MS
Enumeration date
06/16/2006
Last updated
07/08/2007
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