1104910322 NPI number — HATTIESBURG CLINIC PA

Table of content: (NPI 1104910322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104910322 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:
Provider Other Organization Name Type Code:
6
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:
1104910322
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2020
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:
601-579-5488
Provider Business Mailing Address Fax Number:
601-579-5240

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 PINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAYLORSVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39168-5432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-785-6911
Provider Business Practice Location Address Fax Number:
601-785-6988
Provider Enumeration Date:
10/03/2006

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:
601-268-5601

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 09014991 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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