Healthcare Provider Details

I. General information

NPI: 1083643761
Provider Name (Legal Business Name): J.C. PASSMAN MDPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 09/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 SGT PRENTISS DR SUITE 103
NATCHEZ MS
39120-4792
US

IV. Provider business mailing address

46 SGT PRENTISS DR SUITE 103
NATCHEZ MS
39120-4792
US

V. Phone/Fax

Practice location:
  • Phone: 601-442-9654
  • Fax: 601-442-9790
Mailing address:
  • Phone: 601-442-9654
  • Fax: 601-442-9790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number05227
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT0333
License Number StateMS

VIII. Authorized Official

Name: DR. ROBERT BRIAN HAIMSON
Title or Position: PRESIDENT
Credential: MD
Phone: 601-442-9654