Provider Demographics
NPI:1407895584
Name:ER PHYSICIAN GROUP AT JACKSON HOSPITAL
Entity Type:Organization
Organization Name:ER PHYSICIAN GROUP AT JACKSON HOSPITAL
Other - Org Name:WOMENS HEALTHCARE OF THE PANHANDLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HIDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-718-2644
Mailing Address - Street 1:4298 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-2173
Mailing Address - Country:US
Mailing Address - Phone:850-482-5787
Mailing Address - Fax:850-482-8108
Practice Address - Street 1:4298 5TH AVE
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2173
Practice Address - Country:US
Practice Address - Phone:850-482-5787
Practice Address - Fax:850-482-8108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78684 AND ME93313174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL054877400Medicaid
FL270213400Medicaid
FL38679OtherBLUE CROSS
FL0142OtherMEDICARE FIRST COAST
FL272901600Medicaid
FL0142OtherMEDICARE FIRST COAST
I43649Medicare UPIN
G34885Medicare UPIN
FL38679OtherBLUE CROSS