Provider Demographics
NPI:1942449368
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:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-749-3119
Mailing Address - Street 1:801 GOODYEAR BLVD
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-3221
Mailing Address - Country:US
Mailing Address - Phone:888-447-2450
Mailing Address - Fax:
Practice Address - Street 1:1702 HIGHWAY 11 N
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-2016
Practice Address - Country:US
Practice Address - Phone:601-798-4711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-09
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSDP4385OtherRAILROAD MCARE
MS07620530Medicaid
MS302G701483Medicare PIN