Provider Demographics
NPI:1508899824
Name:HATTIESBURG CLINIC, PA
Entity Type:Organization
Organization Name:HATTIESBURG CLINIC, PA
Other - Org Name:WIGGINS DIALYSIS UNIT
Other - Org Type:Doing Business As
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:601-928-2998
Mailing Address - Fax:601-928-2967
Practice Address - Street 1:503 FIRST ST S
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-2763
Practice Address - Country:US
Practice Address - Phone:601-928-2998
Practice Address - Fax:601-928-2967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS5000477OtherUNITED HEALTHCARE
MS00220236Medicaid
MS000050533OtherBLUE CROSS BLUE SHIELD MS
MS00220236Medicaid