Provider Demographics
NPI:1093929184
Name:E-TOWN NEUROSURGERY LLC
Entity Type:Organization
Organization Name:E-TOWN NEUROSURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THAD
Authorized Official - Middle Name:R
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-769-5551
Mailing Address - Street 1:1700 RING RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-9497
Mailing Address - Country:US
Mailing Address - Phone:270-769-5551
Mailing Address - Fax:270-765-3919
Practice Address - Street 1:1700 RING RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-9497
Practice Address - Country:US
Practice Address - Phone:270-769-5551
Practice Address - Fax:270-765-3919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00307Medicare PIN