Provider Demographics
NPI:1982824579
Name:SPINE MEDICAL CENTER OF HATTIESBURG
Entity Type:Organization
Organization Name:SPINE MEDICAL CENTER OF HATTIESBURG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVIDE
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-264-9448
Mailing Address - Street 1:PO BOX 2156
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39505-2156
Mailing Address - Country:US
Mailing Address - Phone:228-865-4731
Mailing Address - Fax:228-863-5616
Practice Address - Street 1:1 LINCOLN PKWY
Practice Address - Street 2:SUITE 104
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3262
Practice Address - Country:US
Practice Address - Phone:601-264-9448
Practice Address - Fax:601-264-9449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14446207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty