Provider Demographics
NPI:1942217120
Name:INTERNAL MEDICINE GROUP, P.A.
Entity Type:Organization
Organization Name:INTERNAL MEDICINE GROUP, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:H
Authorized Official - Last Name:NOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-982-1283
Mailing Address - Street 1:971 LAKELAND DR STE 250
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4620
Mailing Address - Country:US
Mailing Address - Phone:601-982-1283
Mailing Address - Fax:601-987-9060
Practice Address - Street 1:971 LAKELAND DR STE 250
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4620
Practice Address - Country:US
Practice Address - Phone:601-982-1283
Practice Address - Fax:601-987-9060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSCB0119OtherRAILROAD MEDICARE
MS09011302Medicaid
MSCB0119OtherRAILROAD MEDICARE