Basic Information
| Provider Information | |||||||||
| NPI: | 1598879009 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIGESTIVE DISEASES CENTER OF HATTIESBURG, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 METHODIST HOSPITAL BLVD | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394021295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012685189 | ||||||||
| FaxNumber: | 6012685006 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 METHODIST HOSPITAL BLVD | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394021295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012685189 | ||||||||
| FaxNumber: | 6012685006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BUCKLEY | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6012685189 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | 02358833 | 05 | MS | MEDICAID | P00138452 | 01 | MS | RAILROAD MEDICARE | OTHER |