Basic Information
| Provider Information | |||||||||
| NPI: | 1548710726 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HATTIESBURG CLINIC PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | THE DERMATOLOGY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 S 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013589972 | ||||||||
| FaxNumber: | 6015795240 | ||||||||
| Practice Location | |||||||||
| Address1: | 146 HIGHLAND PKWY | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PICAYUNE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394665575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013589972 | ||||||||
| FaxNumber: | 6013589558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2016 | ||||||||
| LastUpdateDate: | 02/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BATSON | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6012646000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.