Provider Demographics
NPI:1548219884
Name:PREMIER MEDICAL GROUP OF MISSISSIPPI LLC
Entity Type:Organization
Organization Name:PREMIER MEDICAL GROUP OF MISSISSIPPI LLC
Other - Org Name:JACKSON MEDICAL CLINIC LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:BETHEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-352-2273
Mailing Address - Street 1:PO BOX 23996
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3996
Mailing Address - Country:US
Mailing Address - Phone:601-206-6113
Mailing Address - Fax:601-206-6052
Practice Address - Street 1:501 MARSHALL ST
Practice Address - Street 2:SUITE 208
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:2006-05-05
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014760Medicaid
MSCD1075OtherRAILROAD MEDICARE
MS=========OtherBCBS OF MISSISSIPPI
MS3904490002Medicare NSC
MSC02360Medicare PIN