Healthcare Provider Details

I. General information

NPI: 1699921197
Provider Name (Legal Business Name): THE PEDIATRIC NEUROLOGY CLINIC OF HATTIESBURG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2008
Last Update Date: 08/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5003 HARDY ST STE 200
HATTIESBURG MS
39402-1331
US

IV. Provider business mailing address

5003 HARDY ST STE 200
HATTIESBURG MS
39402-1331
US

V. Phone/Fax

Practice location:
  • Phone: 601-296-3050
  • Fax: 601-296-3060
Mailing address:
  • Phone: 601-296-3050
  • Fax: 601-296-3060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. STEPHANIE ROBINETT
Title or Position: OWNER
Credential: M.D.
Phone: 601-296-3050