Healthcare Provider Details

I. General information

NPI: 1265564041
Provider Name (Legal Business Name): HATTIESBURG ANESTHESIA ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 HARDY ST
HATTIESBURG MS
39402-1308
US

IV. Provider business mailing address

158 W MAIN ST
SPARTANBURG SC
29306-2333
US

V. Phone/Fax

Practice location:
  • Phone: 601-268-8000
  • Fax:
Mailing address:
  • Phone: 864-591-1540
  • Fax: 864-591-1455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: KENNETH RAYNOR ELLINGTON
Title or Position: PRESIDENT
Credential: MD
Phone: 864-591-1540