Provider Demographics
NPI:1427090398
Name:FGH TRAUMA SURGERY CLINIC
Entity type:Organization
Organization Name:FGH TRAUMA SURGERY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-288-4225
Mailing Address - Street 1:PO BOX 16745
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-6745
Mailing Address - Country:US
Mailing Address - Phone:601-288-2690
Mailing Address - Fax:
Practice Address - Street 1:6051 HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7200
Practice Address - Country:US
Practice Address - Phone:601-288-2690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05102728Medicaid
MS05102728Medicaid