Basic Information
| Provider Information | |||||||||
| NPI: | 1427090398 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FGH TRAUMA SURGERY CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16745 | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394046745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012882690 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6051 HIGHWAY 49 | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012882690 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 09/12/2017 | ||||||||
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| AuthorizedOfficialLastName: | HESTER | ||||||||
| AuthorizedOfficialFirstName: | BEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6012884225 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 05102728 | 05 | MS | MEDICAID |