Provider Demographics
NPI:1861674723
Name:JACKSON SURGICAL GROUP PA
Entity Type:Organization
Organization Name:JACKSON SURGICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:601-946-2200
Mailing Address - Street 1:1600 N STATE ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1689
Mailing Address - Country:US
Mailing Address - Phone:601-944-1717
Mailing Address - Fax:601-944-9780
Practice Address - Street 1:1190 N STATE ST
Practice Address - Street 2:SUITE L01
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2413
Practice Address - Country:US
Practice Address - Phone:601-292-4292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06450208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013125Medicaid
MS09013125Medicaid