Basic Information
Provider Information | |||||||||
NPI: | 1780275495 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HATTIESBURG CLINIC, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 415 S 28TH AVE | ||||||||
Address2: |   | ||||||||
City: | HATTIESBURG | ||||||||
State: | MS | ||||||||
PostalCode: | 394017246 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6015795463 | ||||||||
FaxNumber: | 6015795240 | ||||||||
Practice Location | |||||||||
Address1: | ORLEANS PARK FAMILY MEDICINE | ||||||||
Address2: | 15 ORLEANS DRIVE | ||||||||
City: | HATTIESBURG | ||||||||
State: | MS | ||||||||
PostalCode: | 39402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6015795050 | ||||||||
FaxNumber: | 6012966872 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/27/2021 | ||||||||
LastUpdateDate: | 01/27/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BATSON | ||||||||
AuthorizedOfficialFirstName: | BRYAN | ||||||||
AuthorizedOfficialMiddleName: | N | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 6012646000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 01/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.