Provider Demographics
NPI:1669405981
Name:HATTIESBURG CLINIC, PA
Entity type:Organization
Organization Name:HATTIESBURG CLINIC, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTCOR
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:BATSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
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:601-268-5700
Mailing Address - Fax:601-268-5777
Practice Address - Street 1:14 BAY AVE
Practice Address - Street 2:
Practice Address - City:BAY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39422-9206
Practice Address - Country:US
Practice Address - Phone:601-764-6427
Practice Address - Fax:601-764-6429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS5000477OtherUNITED HEALTHCARE
MS00220502Medicaid
MS000050575OtherBLUE CROSS BLUE SHIELD MS
MS00220502Medicaid