Provider Demographics
NPI:1245754506
Name:JACKSON LIVER AND GI SPECIALISTS INC.
Entity Type:Organization
Organization Name:JACKSON LIVER AND GI SPECIALISTS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BORG
Authorized Official - Suffix:
Authorized Official - Credentials:MD MHSC
Authorized Official - Phone:769-251-5674
Mailing Address - Street 1:971 LAKELAND DR STE 1159
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4609
Mailing Address - Country:US
Mailing Address - Phone:769-251-5674
Mailing Address - Fax:
Practice Address - Street 1:971 LAKELAND DR STE 1159
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4609
Practice Address - Country:US
Practice Address - Phone:769-251-5674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-28
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02752313Medicaid