1407801194 NPI number — ER PHYSICIAN GROUP AT JACKSON HOSPITAL

Table of content: (NPI 1407801194)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407801194 NPI number — ER PHYSICIAN GROUP AT JACKSON HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ER PHYSICIAN GROUP AT JACKSON HOSPITAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407801194
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4250 HOSPITAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIANNA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32446-1917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-526-2200
Provider Business Mailing Address Fax Number:
850-718-2649

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4250 HOSPITAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIANNA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32446-1917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-526-2200
Provider Business Practice Location Address Fax Number:
850-718-2649
Provider Enumeration Date:
05/23/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CONNOLLY
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
850-718-2623

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282NR1301X , with the licence number: 3999 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 054877400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38679 . This is a "BLUE CROSS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: CJ6133 . This is a "MEDICARE RAIL ROAD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".