Healthcare Provider Details

I. General information

NPI: 1831299130
Provider Name (Legal Business Name): HATTIESBURG CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 PARKWAY LN
PETAL MS
39465-3035
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 601-544-7404
  • Fax: 601-584-6457
Mailing address:
  • Phone: 601-544-7404
  • Fax: 601-584-6457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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