Healthcare Provider Details

I. General information

NPI: 1255738035
Provider Name (Legal Business Name): HMG GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2014
Last Update Date: 11/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4436 N STATE ST SUITE A1
JACKSON MS
39206-5334
US

IV. Provider business mailing address

4436 N STATE ST SUITE A1
JACKSON MS
39206-5334
US

V. Phone/Fax

Practice location:
  • Phone: 601-383-2036
  • Fax: 601-981-5819
Mailing address:
  • Phone: 601-383-2036
  • Fax: 601-981-5819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR860365
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR878138
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberR860365
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number07980
License Number StateMS

VIII. Authorized Official

Name: JOHNATHAN CHAD GIBSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 601-951-9197