Provider Demographics
NPI:1982836037
Name:BETHANY R HAIRSTON MD
Entity Type:Organization
Organization Name:BETHANY R HAIRSTON MD
Other - Org Name:VITALITY DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:BETHANY
Authorized Official - Middle Name:R
Authorized Official - Last Name:HAIRSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-328-3375
Mailing Address - Street 1:724 LEIGH DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-3098
Mailing Address - Country:US
Mailing Address - Phone:662-328-3375
Mailing Address - Fax:662-328-3395
Practice Address - Street 1:724 LEIGH DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-3098
Practice Address - Country:US
Practice Address - Phone:662-328-3375
Practice Address - Fax:662-328-3395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-21
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty