Basic Information
| Provider Information | |||||||||
| NPI: | 1659779445 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED MEDICAL STAFF OF JACKSON PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 828 N PARKWAY | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383053032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314220330 | ||||||||
| FaxNumber: | 7314220499 | ||||||||
| Practice Location | |||||||||
| Address1: | 828 N PARKWAY | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383053032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314220330 | ||||||||
| FaxNumber: | 7314220499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2014 | ||||||||
| LastUpdateDate: | 12/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7314220330 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JACKSON CLINIC, PA | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RH0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RI0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RN0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RS0012X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.