1962602458 NPI number — F. DANIEL JACKSON, MD, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962602458 NPI number — F. DANIEL JACKSON, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
F. DANIEL JACKSON, MD, PA
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:
THE IMAGING CENTER
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:
1962602458
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1692
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CUMBERLAND
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21501-1692
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-759-3817
Provider Business Mailing Address Fax Number:
301-759-3043

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
715 WILLIAMS STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUMBERLAND
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-759-3410
Provider Business Practice Location Address Fax Number:
301-759-3522
Provider Enumeration Date:
07/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
F.
Authorized Official Middle Name:
DANIEL
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
301-759-3410

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0200X , with the licence number: D0020433 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 440082800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 305591400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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