Provider Demographics
NPI:1366832883
Name:JACKSON ORTHOPEDIC AND SPINE CLINIC
Entity Type:Organization
Organization Name:JACKSON ORTHOPEDIC AND SPINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GIRIRAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-568-9921
Mailing Address - Street 1:832 HIGHWAY 15 N
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-8284
Mailing Address - Country:US
Mailing Address - Phone:606-568-9921
Mailing Address - Fax:330-773-3698
Practice Address - Street 1:832 HIGHWAY 15 N
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-8284
Practice Address - Country:US
Practice Address - Phone:606-568-9921
Practice Address - Fax:330-773-3698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42230207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty