Provider Demographics
NPI:1225105315
Name:JACKSON LUNG CLINIC
Entity Type:Organization
Organization Name:JACKSON LUNG CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAZIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-936-6001
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39205-0967
Mailing Address - Country:US
Mailing Address - Phone:601-936-6001
Mailing Address - Fax:601-936-4389
Practice Address - Street 1:1151 N STATE ST
Practice Address - Street 2:SUITE 301
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2407
Practice Address - Country:US
Practice Address - Phone:601-352-0041
Practice Address - Fax:601-352-0043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015305Medicaid
MSC02536Medicare ID - Type UnspecifiedCLINIC CODE