Provider Demographics
NPI:1669242822
Name:JEA SURGICAL, LLC
Entity type:Organization
Organization Name:JEA SURGICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHRIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-353-2020
Mailing Address - Street 1:1026 BAPTIST CIR STE 101
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-2028
Mailing Address - Country:US
Mailing Address - Phone:601-353-2020
Mailing Address - Fax:769-567-1069
Practice Address - Street 1:1026 BAPTIST CIRCLE
Practice Address - Street 2:SUITE 101
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110
Practice Address - Country:US
Practice Address - Phone:601-353-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-08
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty