Healthcare Provider Details

I. General information

NPI: 1447350749
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: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 HALL ST
WIGGINS MS
39577-2110
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 601-928-4412
  • Fax: 601-928-4792
Mailing address:
  • Phone: 601-579-5463
  • Fax: 601-579-5240

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