Provider Demographics
NPI:1114014479
Name:HATTIESBURG CLINIC PA
Entity Type:Organization
Organization Name:HATTIESBURG CLINIC PA
Other - Org Name:HATTIESBURG CLINIC DERMATOLOGY
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:601-264-8433
Mailing Address - Fax:601-264-8800
Practice Address - Street 1:6 MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7230
Practice Address - Country:US
Practice Address - Phone:601-264-8433
Practice Address - Fax:601-264-8800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00506274Medicaid
MS00506274Medicaid
MS00506274Medicaid