Healthcare Provider Details

I. General information

NPI: 1861674723
Provider Name (Legal Business Name): JACKSON SURGICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 04/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 N STATE ST SUITE L01
JACKSON MS
39202-2413
US

IV. Provider business mailing address

1600 N STATE ST SUITE 400
JACKSON MS
39202-1689
US

V. Phone/Fax

Practice location:
  • Phone: 601-292-4292
  • Fax:
Mailing address:
  • Phone: 601-944-1717
  • Fax: 601-944-9780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number06450
License Number StateMS

VIII. Authorized Official

Name: AUSTIN FREDERICK PARKER II
Title or Position: GENERAL SURGEON
Credential: MD
Phone: 601-946-2200