Provider Demographics
NPI:1255738035
Name:HMG GROUP LLC
Entity type:Organization
Organization Name:HMG GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHNATHAN
Authorized Official - Middle Name:CHAD
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-951-9197
Mailing Address - Street 1:4436 N STATE ST
Mailing Address - Street 2:SUITE A1
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-5334
Mailing Address - Country:US
Mailing Address - Phone:601-383-2036
Mailing Address - Fax:601-981-5819
Practice Address - Street 1:4436 N STATE ST
Practice Address - Street 2:SUITE A1
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-5334
Practice Address - Country:US
Practice Address - Phone:601-383-2036
Practice Address - Fax:601-981-5819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-22
Last Update Date:2014-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR860365363LA2200X, 363LW0102X
MSR878138363LF0000X
MS07980207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04136595Medicaid
MS03727355Medicaid
MS04457077Medicaid
MSD73529Medicare UPIN
MS080004336Medicare PIN