Provider Demographics
NPI:1407357742
Name:ADMIRAL MEDICAL MANAGEMENT GROUP LLC
Entity Type:Organization
Organization Name:ADMIRAL MEDICAL MANAGEMENT GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN CNP
Authorized Official - Prefix:
Authorized Official - First Name:KETURA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN CNP
Authorized Official - Phone:216-855-7775
Mailing Address - Street 1:3356 GREENS POINTE DR
Mailing Address - Street 2:
Mailing Address - City:TWINSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44087-4911
Mailing Address - Country:US
Mailing Address - Phone:440-815-1781
Mailing Address - Fax:
Practice Address - Street 1:3356 GREENS POINTE DR
Practice Address - Street 2:
Practice Address - City:TWINSBURG
Practice Address - State:OH
Practice Address - Zip Code:44087-4911
Practice Address - Country:US
Practice Address - Phone:440-815-1781
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH366986163WA2000X
OH261Q00000X, 261QM1300X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No163WA2000XNursing Service ProvidersRegistered NurseAdministratorGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care