=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902617632
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HATTIESBURG CLINIC, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2025
-----------------------------------------------------
Last Update Date | 01/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 502 BROAD ST STE 2
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39429-3037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-736-8282
-----------------------------------------------------
Fax | 601-736-8333
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 S 28TH AVE
-----------------------------------------------------
City | HATTIESBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39401-7246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-264-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | BRYAN N BATSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 601-264-6000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------