Healthcare Provider Details

I. General information

NPI: 1396156394
Provider Name (Legal Business Name): MATTHEW BRETT HYATT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 N STATE ST STE 404
JACKSON MS
39202-2457
US

IV. Provider business mailing address

111 EDENBERG BND
MADISON MS
39110-2302
US

V. Phone/Fax

Practice location:
  • Phone: 601-292-4261
  • Fax: 601-292-4262
Mailing address:
  • Phone: 601-319-6015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberDO-06090
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number55769
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberDO-06090
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number27446
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: