Provider Demographics
NPI:1093736795
Name:HATTIESBURG CLINIC PA
Entity Type:Organization
Organization Name:HATTIESBURG CLINIC PA
Other - Org Name:AMBULATORY SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:BATSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-268-5601
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:601-579-5488
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-579-5075
Practice Address - Fax:601-579-5039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770554Medicaid
LA1503916Medicaid
LA1503916Medicaid
MS00770554Medicaid