Basic Information
| Provider Information | |||||||||
| NPI: | 1548219884 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER MEDICAL GROUP OF MISSISSIPPI LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JACKSON MEDICAL CLINIC LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23996 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392253996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012066113 | ||||||||
| FaxNumber: | 6012066052 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 MARSHALL ST | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392021651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013522273 | ||||||||
| FaxNumber: | 6013534414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 02/16/2009 | ||||||||
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| AuthorizedOfficialLastName: | BETHEA | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6013522273 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 09014760 | 05 | MS | MEDICAID | CD1075 | 01 | MS | RAILROAD MEDICARE | OTHER |