Provider Demographics
NPI:1306922653
Name:WOMENS PAVILION OF SOUTH MISSISSIPPI, PLLC
Entity type:Organization
Organization Name:WOMENS PAVILION OF SOUTH MISSISSIPPI, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:HOLLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:601-450-9425
Mailing Address - Street 1:6524 U S HIGHWAY 98
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8569
Mailing Address - Country:US
Mailing Address - Phone:601-268-9393
Mailing Address - Fax:601-268-9559
Practice Address - Street 1:551 EAGLE DAY AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-3605
Practice Address - Country:US
Practice Address - Phone:601-736-6137
Practice Address - Fax:601-731-1383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-30
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014107Medicaid
MSC03089Medicare PIN
TN253945Medicare Oscar/Certification