Provider Demographics
NPI:1790827038
Name:PREMIER MEDICAL GROUP OF MISSISSIPPI LLC
Entity Type:Organization
Organization Name:PREMIER MEDICAL GROUP OF MISSISSIPPI LLC
Other - Org Name:KOSCIUSKO MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-289-1800
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:601-206-6100
Mailing Address - Fax:601-206-6052
Practice Address - Street 1:332 HIGHWAY 12 W
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3209
Practice Address - Country:US
Practice Address - Phone:662-289-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015162Medicaid
MSCG1185OtherRAILROAD MEDICARE
MS09015162Medicaid
MS09015162Medicaid
MSCG1185OtherRAILROAD MEDICARE