Provider Demographics
NPI:1053483735
Name:PREMIER MEDICAL MANAGEMENT OF MISSISSIPPI, INC
Entity Type:Organization
Organization Name:PREMIER MEDICAL MANAGEMENT OF MISSISSIPPI, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PATIENT'S ACCOUNTS
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-352-2273
Mailing Address - Street 1:864 WILSON DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4512
Mailing Address - Country:US
Mailing Address - Phone:601-206-6100
Mailing Address - Fax:601-206-6052
Practice Address - Street 1:501 MARSHALL ST
Practice Address - Street 2:SUITE 201
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1651
Practice Address - Country:US
Practice Address - Phone:601-352-2273
Practice Address - Fax:601-353-4414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770341Medicaid
MS490004328OtherRAILROAD MEDICARE
MS490004328OtherRAILROAD MEDICARE
MS490004328OtherRAILROAD MEDICARE