Basic Information
| Provider Information | |||||||||
| NPI: | 1093870339 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSON HOSPITAL AND CLINIC, INC | ||||||||
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| OtherOrganizationName: | JACKSON FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2257 TAYLOR RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361177790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342709914 | ||||||||
| FaxNumber: | 3342703195 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 PINE ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361060165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342655577 | ||||||||
| FaxNumber: | 3342655584 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 04/10/2013 | ||||||||
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| AuthorizedOfficialLastName: | SCHOLL | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3342938000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.