Provider Demographics
NPI:1174546345
Name:BEISEL, BERTHOLD (MD)
Entity type:Individual
Prefix:
First Name:BERTHOLD
Middle Name:
Last Name:BEISEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-736-8282
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:502 BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-3037
Practice Address - Country:US
Practice Address - Phone:601-736-8282
Practice Address - Fax:601-736-8333
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17957207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1739685Medicaid
P00007519OtherRAILROAD MEDICARE
MS03871775Medicaid
MS640507572TLOtherAMERICAN ADMIN GROUP
MS640507572TLOtherAMERICAN ADMIN GROUP
MS03871775Medicaid