Provider Demographics
NPI:1659479210
Name:PAUL MATHERNE, M.D.
Entity Type:Organization
Organization Name:PAUL MATHERNE, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLO
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:G
Authorized Official - Last Name:MATHERNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-388-4862
Mailing Address - Street 1:180B DEBUYS RD
Mailing Address - Street 2:SUITE #223
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-4404
Mailing Address - Country:US
Mailing Address - Phone:228-388-4862
Mailing Address - Fax:228-388-2556
Practice Address - Street 1:180B DEBUYS RD
Practice Address - Street 2:SUITE #223
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4404
Practice Address - Country:US
Practice Address - Phone:228-388-4862
Practice Address - Fax:228-388-2556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09445305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000018917Medicaid
MS437709303OtherBCBS OF MS/ BCBS OF ALA.
MSD00879Medicare UPIN
MS000018917Medicaid