Full Name | |
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Speciality | Family Medicine |
Location | 50 Parkway Ln, Petal, Mississippi |
Authorized Official Name and Position | Bryan N Batson (EXECUTIVE DIRECTOR) |
Authorized Official Contact | 6012646000 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
---|---|
415 S 28th Ave Hattiesburg MS 39401-7246 Ph: (601) 544-7404 | 50 Parkway Ln Petal MS 39465-3035 Ph: (601) 544-7404 |
NPI Number | 1831299130 |
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Provider Enumeration Date | 09/25/2006 |
Last Update Date | 02/23/2021 |
Medicare PECOS PAC ID | 5193706794 |
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Medicare Enrollment ID | O20100930080282 |
Identifier | Type | State | Issuer |
---|---|---|---|
1831299130 | NPI | - | NPPES |
07605763 | Medicaid | MS |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
207Q00000X | Family Medicine | (* (Not Available)) | Primary |