Healthcare Provider Details

I. General information

NPI: 1265528160
Provider Name (Legal Business Name): HATTIESBURG CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 FIFTH STREET
COLLINS MS
39428
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 601-765-4414
  • Fax: 601-765-9141
Mailing address:
  • Phone: 601-765-4414
  • Fax: 601-765-9141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRYAN N BATSON
Title or Position: EXECUTIVE DIRECTOR
Credential: MD
Phone: 601-268-5601