Provider Demographics
NPI:1730310335
Name:HIGHLAND COMMUNITY CLINIC NETWORK
Entity Type:Organization
Organization Name:HIGHLAND COMMUNITY CLINIC NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA, FHFMA
Authorized Official - Phone:601-749-3121
Mailing Address - Street 1:1375 CORPORATE SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-3147
Mailing Address - Country:US
Mailing Address - Phone:985-726-2655
Mailing Address - Fax:985-643-9808
Practice Address - Street 1:801 GOODYEAR BLVD
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3221
Practice Address - Country:US
Practice Address - Phone:985-726-2655
Practice Address - Fax:985-643-9808
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HIGHLAND COMMUNITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-30
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X
MS19353207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DP4385OtherRAILROAD MCARE
MS03900238Medicaid
LA2112015Medicaid
DP4385OtherRAILROAD MCARE