Basic Information
| Provider Information | |||||||||
| NPI: | 1760770754 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSON HOSPITAL AND CLINIC, INC. | ||||||||
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| OtherOrganizationName: | JACKSON CLINIC UROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1722 PINE ST | ||||||||
| Address2: | STE 503 | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361061103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342709914 | ||||||||
| FaxNumber: | 3342703195 | ||||||||
| Practice Location | |||||||||
| Address1: | 1722 PINE ST | ||||||||
| Address2: | SUITE 502 | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361061103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342938588 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2011 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | HERRING | ||||||||
| AuthorizedOfficialFirstName: | TARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | REVENUE CYCLE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3342402337 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MD.31014 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.