Provider Demographics
NPI:1104166362
Name:JACKSON ANESTHESIA PAIN CENTER, LLC
Entity type:Organization
Organization Name:JACKSON ANESTHESIA PAIN CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARROLL
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-709-0607
Mailing Address - Street 1:1190 N STATE ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2413
Mailing Address - Country:US
Mailing Address - Phone:601-709-0607
Mailing Address - Fax:601-709-2110
Practice Address - Street 1:1190 N STATE ST
Practice Address - Street 2:SUITE 300
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2413
Practice Address - Country:US
Practice Address - Phone:601-709-0607
Practice Address - Fax:601-709-2110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12138208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty