NPIMap

Organization Active NPI

Hattiesburg Clinic PA

Doing business as Runnelstown Clinic

  • Family Medicine Physician
  • Petal, MS
National Provider Identifier
1649356767
Registry record updated Feb 18, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
HATTIESBURG CLINIC PA
Doing business as
Runnelstown Clinic
Practice address
15 Pumping Station Rd
Petal, MS 39465-8325
Phone
(601) 583-1559
Fax
(601) 583-1573
NPI assigned
Oct 31, 2006
Last updated
Feb 18, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 18, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Bryan N Batson, MD
Title
Executive Director
Phone
(601) 264-6000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X Primary

Addresses

Primary practice location

15 Pumping Station Rd
Petal, MS 39465-8325

Mailing address

415 S 28TH Ave
Hattiesburg, MS 39401-7246
Phone (601) 579-5463

Other identifiers 1

IdentifierTypeStateIssuer
09014620MedicaidMS

Other names 1

  • Runnelstown Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1649356767. Details of each certification follow.

Rural health clinic certification: CCN 258922

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
RUNNELSTOWN CLINIC ( CLOSED )
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Mar 17, 1997
Last certification
May 1, 2017
Ownership / control type
2B
Facility address
15 Pumping Station Road
Petal, MS 39465

National Provider Directory

National Provider Directory
Tax ID family
Hattiesburg Clinic PA136 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 24

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 24

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1162252800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1613606400000",
    "number": "1649356767",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "415 S 28TH AVE",
            "city": "HATTIESBURG",
            "state": "MS",
            "postal_code": "394017246",
            "telephone_number": "601-579-5463",
            "fax_number": "601-579-5240"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "15 PUMPING STATION RD",
            "city": "PETAL",
            "state": "MS",
            "postal_code": "394658325",
            "telephone_number": "601-583-1559",
            "fax_number": "601-583-1573"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HATTIESBURG CLINIC PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-31",
        "last_updated": "2021-02-18",
        "certification_date": "2021-02-18",
        "status": "A",
        "authorized_official_last_name": "BATSON",
        "authorized_official_first_name": "BRYAN",
        "authorized_official_middle_name": "N",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "601-264-6000",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09014620",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Runnelstown Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Runnelstown Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Petal, MS

Sources for this page

Verify at the official NPI Registry.