1821021155 NPI number — HATTIESBURG CLINIC, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821021155 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:
TYLERTOWN DIALYSIS UNIT
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:
1821021155
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 S 28TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39401-7246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-222-0311
Provider Business Mailing Address Fax Number:
601-222-0351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4820 PLAZA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLERTOWN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39667-9221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-222-0311
Provider Business Practice Location Address Fax Number:
601-222-0351
Provider Enumeration Date:
07/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BATSON
Authorized Official First Name:
BRYAN
Authorized Official Middle Name:
N
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
601-264-6000

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5000477 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00220570 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000050656 . This is a "BLUE CROSS BLUE SHIELD MS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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