Healthcare Provider Details

I. General information

NPI: 1558379263
Provider Name (Legal Business Name): KEVIN MARK PASSER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 11/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5317-4 OLD HIGHWAY 11
HATTIESBURG MS
39402
US

IV. Provider business mailing address

6068 HIGHWAY 98 WEST SUITE 1-255
HATTIESBURG MS
39402
US

V. Phone/Fax

Practice location:
  • Phone: 601-261-9101
  • Fax: 601-261-9102
Mailing address:
  • Phone: 601-261-9101
  • Fax: 601-261-9102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number13970
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number13970
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: