Healthcare Provider Details

I. General information

NPI: 1104166362
Provider Name (Legal Business Name): JACKSON ANESTHESIA PAIN CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2013
Last Update Date: 02/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 N STATE ST SUITE 300
JACKSON MS
39202-2413
US

IV. Provider business mailing address

1190 N STATE ST SUITE 300
JACKSON MS
39202-2413
US

V. Phone/Fax

Practice location:
  • Phone: 601-709-0607
  • Fax: 601-709-2110
Mailing address:
  • Phone: 601-709-0607
  • Fax: 601-709-2110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number12138
License Number StateMS

VIII. Authorized Official

Name: DR. CARROLL M MCLEOD
Title or Position: OWNER
Credential: MD
Phone: 601-709-0607