Basic Information
| Provider Information | |||||||||
| NPI: | 1861674723 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSON SURGICAL GROUP PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 N STATE ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392021689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019441717 | ||||||||
| FaxNumber: | 6019449780 | ||||||||
| Practice Location | |||||||||
| Address1: | 1190 N STATE ST | ||||||||
| Address2: | SUITE L01 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012924292 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2007 | ||||||||
| LastUpdateDate: | 04/25/2014 | ||||||||
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| AuthorizedOfficialLastName: | PARKER | ||||||||
| AuthorizedOfficialFirstName: | AUSTIN | ||||||||
| AuthorizedOfficialMiddleName: | FREDERICK | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL SURGEON | ||||||||
| AuthorizedOfficialTelephone: | 6019462200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 06450 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 09013125 | 05 | MS | MEDICAID |