Healthcare Provider Details

I. General information

NPI: 1336534270
Provider Name (Legal Business Name): HATTIESBURG CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 LINCOLN PKWY STE 300
HATTIESBURG MS
39402-3261
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 601-261-1600
  • Fax:
Mailing address:
  • Phone: 601-579-5463
  • Fax: 601-579-5240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: BRYAN N BATSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 601-264-6000