Provider Demographics
NPI:1225029390
Name:JACKSON MADISON COUNTY GENERAL HOSPITAL
Entity Type:Organization
Organization Name:JACKSON MADISON COUNTY GENERAL HOSPITAL
Other - Org Name:WEST TENNESSEE REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-541-5000
Mailing Address - Street 1:620 SKYLINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3901
Mailing Address - Country:US
Mailing Address - Phone:731-541-6930
Mailing Address - Fax:731-541-6218
Practice Address - Street 1:620 SKYLINE DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3901
Practice Address - Country:US
Practice Address - Phone:731-541-6930
Practice Address - Fax:731-541-6218
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSON MADISON COUNTY GENERAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-28
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000078273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN044T002Medicaid
TN044T002Medicaid