MEDICARE: HATTIESBURG CLINIC, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5000477	OTHER	MS	UNITED HEALTHCARE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	000050285	OTHER	MS	BLUE CROSS BLUE SHIELD MS

General Provider Information

NPI Number	:	1952334260
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HATTIESBURG CLINIC, PA

Provider Business Mailing Address
First Line	:	415 S 28TH AVE
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39401-7246
Country	:	US
Telephone Number	:	601-731-6305
Fax Number	:	601-731-2952

Provider Business Practice Location Address
First Line	:	1214 HIGHWAY 98 BYP
Second Line	:
City	:	COLUMBIA
State	:	MS
Zip	:	39429-3703
Country	:	US
Telephone Number	:	601-731-1234
Fax Number	:	601-731-2952

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. BRYAN N BATSON
Credential	:
Telephone Number	:	601-264-6000

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	04/12/2024

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