Provider Demographics
NPI:1487067328
Name:GREATER JACKSON PHYSICIAN GROUP
Entity type:Organization
Organization Name:GREATER JACKSON PHYSICIAN GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SWILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-968-0985
Mailing Address - Street 1:501 MARSHALL ST STE 501
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1615
Mailing Address - Country:US
Mailing Address - Phone:601-899-3990
Mailing Address - Fax:601-960-0583
Practice Address - Street 1:501 MARSHALL ST STE 501
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1615
Practice Address - Country:US
Practice Address - Phone:601-968-0985
Practice Address - Fax:601-960-0583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-09
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06373834Medicaid