1164803367 NPI number — JACKSON HOSPITAL AND CLINIC INC

Table of content: (NPI 1164803367)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164803367 NPI number — JACKSON HOSPITAL AND CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSON HOSPITAL AND CLINIC INC
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:
JACKSON UROLOGY EAST
Provider Other Organization Name Type Code:
3
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:
1164803367
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1722 PINE ST STE 503
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36106-1160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-240-2337
Provider Business Mailing Address Fax Number:
334-293-6859

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
226 MITYLENE PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTGOMERY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36117-3548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-281-7666
Provider Business Practice Location Address Fax Number:
334-293-6859
Provider Enumeration Date:
06/12/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PENNEY
Authorized Official First Name:
KELIN
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
334-240-2337

Provider Taxonomy Codes

  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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