Provider Demographics
NPI:1235112178
Name:JACKSON, FREEMAN RANDOLPH (MD)
Entity Type:Individual
Prefix:
First Name:FREEMAN
Middle Name:RANDOLPH
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 N ELM ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-6302
Mailing Address - Country:US
Mailing Address - Phone:336-274-9617
Mailing Address - Fax:336-482-2177
Practice Address - Street 1:1331 N ELM ST
Practice Address - Street 2:SUITE 200
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-6302
Practice Address - Country:US
Practice Address - Phone:336-274-9617
Practice Address - Fax:336-482-2177
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC227472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1600271OtherUNITED HEALTHCARE
NC23519OtherPARTNERS
NC45552OtherBLUE CROSS BLUE SHIELD
NC300085677OtherRAILROAD MEDICARE
NC8945552Medicaid
NC73479OtherMEDCOST
NC1600271OtherUNITED HEALTHCARE
NC300085677OtherRAILROAD MEDICARE