1861674723 NPI number — JACKSON SURGICAL GROUP PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861674723 NPI number — JACKSON SURGICAL GROUP PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSON SURGICAL GROUP PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861674723
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 N STATE ST
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39202-1689
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-944-1717
Provider Business Mailing Address Fax Number:
601-944-9780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1190 N STATE ST
Provider Second Line Business Practice Location Address:
SUITE L01
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39202-2413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-292-4292
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PARKER
Authorized Official First Name:
AUSTIN
Authorized Official Middle Name:
FREDERICK
Authorized Official Title or Position:
GENERAL SURGEON
Authorized Official Telephone Number:
601-946-2200

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  06450 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 09013125 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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