Healthcare Provider Details

I. General information

NPI: 1760196984
Provider Name (Legal Business Name): JACKSON HEART AND VASCULAR CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2023
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 MEDICAL PKWY STE 101
FLOWOOD MS
39232-1230
US

IV. Provider business mailing address

185 MEDICAL PKWY STE 101
FLOWOOD MS
39232-1230
US

V. Phone/Fax

Practice location:
  • Phone: 405-285-7500
  • Fax:
Mailing address:
  • Phone: 601-414-2501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CASEY MCMAHAN
Title or Position: MANAGER
Credential:
Phone: 405-285-7500