Provider Demographics
NPI:1366746588
Name:THE AKESO GROUP - VICKSBURG
Entity type:Organization
Organization Name:THE AKESO GROUP - VICKSBURG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNATHAN
Authorized Official - Middle Name:MILTON
Authorized Official - Last Name:ISOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-797-9711
Mailing Address - Street 1:5744 NANJACK CIR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-2061
Mailing Address - Country:US
Mailing Address - Phone:901-797-9711
Mailing Address - Fax:901-797-9771
Practice Address - Street 1:2100 HIGHWAY 61 N
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-8211
Practice Address - Country:US
Practice Address - Phone:601-883-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE AKESO GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty