Provider Demographics
NPI:1851488118
Name:HATTIESBURG CLINIC PA
Entity Type:Organization
Organization Name:HATTIESBURG CLINIC PA
Other - Org Name:DERMATOLOGY CLINIC OF HATTIESBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:BATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
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:601-268-5252
Mailing Address - Fax:601-296-3501
Practice Address - Street 1:104 ASBURY CIR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1302
Practice Address - Country:US
Practice Address - Phone:601-268-5252
Practice Address - Fax:601-296-3501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02756871Medicaid