Provider Demographics
NPI:1306830062
Name:JACKSON, MICHAEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
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: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 1:506 RIVERSIDE PKWY NE
Practice Address - Street 2:STE 200
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-2902
Practice Address - Country:US
Practice Address - Phone:706-266-2383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055376207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000807474DMedicaid
1164745782OtherMEDICARE TYPE 2 ORGANIZATIONAL NPI
202I080352OtherMEDICARE PTAN
GA000807474BMedicaid
GA000807474CMedicaid
1306830062OtherMEDICARE NPI
P00218237Medicare PIN
GA08BBRKTMedicare PIN
202I080352OtherMEDICARE PTAN