1407861016 NPI number — HATTIESBURG CLINIC PA

Table of content: (NPI 1407861016)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407861016 NPI number — HATTIESBURG CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HATTIESBURG CLINIC PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OWL DRUG STORE
Provider Other Organization Name Type Code:
3
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:
1407861016
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
MEDICAL BLVD
Provider Second Line Business Mailing Address:
STE 2
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-268-5740
Provider Business Mailing Address Fax Number:
601-268-5858

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MEDICAL BLVD
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
HATTIESBURG
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-268-5740
Provider Business Practice Location Address Fax Number:
601-268-5858
Provider Enumeration Date:
07/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ASHLEY
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHCY DIR
Authorized Official Telephone Number:
601-268-2740

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 01821/1.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2045095 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00030291 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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