Provider Demographics
NPI:1457451775
Name:HATTIESBURG CLINIC PA
Entity Type:Organization
Organization Name:HATTIESBURG CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
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:601-264-6000
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:601-579-5463
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:822 MAIN ST
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-2425
Practice Address - Country:US
Practice Address - Phone:601-477-2014
Practice Address - Fax:601-477-9942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06238274Medicaid
MS06238274Medicaid