Provider Demographics
NPI:1215084967
Name:JACKSON ORTHOPAEDIC CLINIC, PA
Entity type:Organization
Organization Name:JACKSON ORTHOPAEDIC CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:GANDY
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:601-981-7212
Mailing Address - Street 1:971 LAKELAND DR
Mailing Address - Street 2:SUITE 950
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4643
Mailing Address - Country:US
Mailing Address - Phone:601-981-7212
Mailing Address - Fax:
Practice Address - Street 1:971 LAKELAND DR
Practice Address - Street 2:SUITE 950
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4643
Practice Address - Country:US
Practice Address - Phone:601-981-7212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07306207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00280226Medicaid
MSC03010Medicare ID - Type Unspecified