Provider Demographics
NPI:1255924346
Name:PMGROUP
Entity type:Organization
Organization Name:PMGROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:CORNELIUS
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO,MD
Authorized Official - Phone:601-329-1321
Mailing Address - Street 1:300 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7715
Mailing Address - Country:US
Mailing Address - Phone:601-329-1321
Mailing Address - Fax:
Practice Address - Street 1:300 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7715
Practice Address - Country:US
Practice Address - Phone:601-329-1321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-19
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No347C00000XTransportation ServicesPrivate VehicleGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS800347OtherHEALTHCARE EMPLOYER PROVIDER