Healthcare Provider Details

I. General information

NPI: 1366746588
Provider Name (Legal Business Name): THE AKESO GROUP - VICKSBURG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2011
Last Update Date: 01/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 HIGHWAY 61 N
VICKSBURG MS
39183-8211
US

IV. Provider business mailing address

5744 NANJACK CIR
MEMPHIS TN
38115-2061
US

V. Phone/Fax

Practice location:
  • Phone: 601-883-5000
  • Fax:
Mailing address:
  • Phone: 901-797-9711
  • Fax: 901-797-9771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHNATHAN MILTON ISOM
Title or Position: CEO
Credential: M.D.
Phone: 901-797-9711