Healthcare Provider Details

I. General information

NPI: 1306922653
Provider Name (Legal Business Name): WOMENS PAVILION OF SOUTH MISSISSIPPI, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2006
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 EAGLE DAY AVE
COLUMBIA MS
39429-3605
US

IV. Provider business mailing address

6524 U S HIGHWAY 98
HATTIESBURG MS
39402-8569
US

V. Phone/Fax

Practice location:
  • Phone: 601-736-6137
  • Fax: 601-731-1383
Mailing address:
  • Phone: 601-268-9393
  • Fax: 601-268-9559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. HOLLEY JOHNSON
Title or Position: ADMINISTRATOR
Credential: MHA
Phone: 601-450-9425