Provider Demographics
NPI:1629022017
Name:MMO OF HATTIESBURG, LLC
Entity type:Organization
Organization Name:MMO OF HATTIESBURG, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-293-6774
Mailing Address - Street 1:728 NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70802-5724
Mailing Address - Country:US
Mailing Address - Phone:225-293-6774
Mailing Address - Fax:225-291-9229
Practice Address - Street 1:990 HARDY ST
Practice Address - Street 2:SUITE 4
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-4161
Practice Address - Country:US
Practice Address - Phone:601-602-0194
Practice Address - Fax:601-602-0197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
C03576Medicare PIN
25-4619Medicare PIN