Provider Demographics
NPI:1154956134
Name:GREATER JACKSON OBGYN LLC
Entity type:Organization
Organization Name:GREATER JACKSON OBGYN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:AMY
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:769-233-8585
Mailing Address - Street 1:501 MARSHALL ST STE 502
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1661
Mailing Address - Country:US
Mailing Address - Phone:769-233-8585
Mailing Address - Fax:601-487-5153
Practice Address - Street 1:501 MARSHALL ST STE 502
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1661
Practice Address - Country:US
Practice Address - Phone:769-233-8585
Practice Address - Fax:601-487-5156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-10
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00118723Medicaid