1710265905 NPI number — JACKSON HOSPITAL AND CLINIC, INC.

Table of content: (NPI 1710265905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710265905 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:
BASIL O. BURNEY, M.D.
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:
1710265905
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1722 PINE ST
Provider Second Line Business Mailing Address:
SUITE 503
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36106-1103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-270-9914
Provider Business Mailing Address Fax Number:
334-270-3195

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 PINE ST
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
MONTGOMERY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36106-0165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-293-8877
Provider Business Practice Location Address Fax Number:
334-293-6803
Provider Enumeration Date:
07/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
VERRECCHIA
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
334-293-8000

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  MD.30788 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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