Provider Demographics
NPI:1164745782
Name:MICHAEL S. JACKSON, MD, PC
Entity Type:Organization
Organization Name:MICHAEL S. JACKSON, MD, PC
Other - Org Name:YOUR PERSONAL PHYSICIAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-266-9090
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:SILVER CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30173-0040
Mailing Address - Country:US
Mailing Address - Phone:706-266-9090
Mailing Address - Fax:706-204-8797
Practice Address - Street 1:701 E 2ND AVE SW
Practice Address - Street 2:SUITE C
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-6148
Practice Address - Country:US
Practice Address - Phone:706-266-9090
Practice Address - Fax:706-204-8797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055376207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08BBRKTOtherMEDICARE PTAN
1306830062OtherMEDICARE INDIVIDUAL NPI
GAC17339Medicare UPIN