Basic Information
| Provider Information | |||||||||
| NPI: | 1942449368 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HIGHLAND COMMUNITY CLINIC NETWORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 GOODYEAR BLVD | ||||||||
| Address2: | |||||||||
| City: | PICAYUNE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394663221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884472450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1702 HIGHWAY 11 N | ||||||||
| Address2: | |||||||||
| City: | PICAYUNE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394662016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017984711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2009 | ||||||||
| LastUpdateDate: | 02/09/2010 | ||||||||
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| AuthorizedOfficialLastName: | STEVENS | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6017493119 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | DP4385 | 01 | MS | RAILROAD MCARE | OTHER | 07620530 | 05 | MS | MEDICAID |