Provider Demographics
NPI:1184635542
Name:PAYNE, HERNANDO C (MD)
Entity Type:Individual
Prefix:
First Name:HERNANDO
Middle Name:C
Last Name:PAYNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23998
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3998
Mailing Address - Country:US
Mailing Address - Phone:662-725-2749
Mailing Address - Fax:662-725-2741
Practice Address - Street 1:1727 E UNION ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-3253
Practice Address - Country:US
Practice Address - Phone:662-332-0373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08032207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR162022001Medicaid
MS00011061Medicaid
AR162022001Medicaid
MS080004108Medicare PIN