Provider Demographics
NPI:1093870339
Name:JACKSON HOSPITAL AND CLINIC, INC
Entity Type:Organization
Organization Name:JACKSON HOSPITAL AND CLINIC, INC
Other - Org Name:JACKSON FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:SCHOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-293-8000
Mailing Address - Street 1:2257 TAYLOR RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-7790
Mailing Address - Country:US
Mailing Address - Phone:334-270-9914
Mailing Address - Fax:334-270-3195
Practice Address - Street 1:1801 PINE ST
Practice Address - Street 2:SUITE 301
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-0165
Practice Address - Country:US
Practice Address - Phone:334-265-5577
Practice Address - Fax:334-265-5584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALH283Medicare PIN