Provider Demographics
NPI:1508048125
Name:JACKSON MEDICAL CENTER PC
Entity Type:Organization
Organization Name:JACKSON MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-335-1779
Mailing Address - Street 1:2387 W JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-3024
Mailing Address - Country:US
Mailing Address - Phone:573-243-9288
Mailing Address - Fax:573-204-7074
Practice Address - Street 1:2387 W JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-3024
Practice Address - Country:US
Practice Address - Phone:573-243-9288
Practice Address - Fax:573-204-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA10692Medicare UPIN
MD6356970001Medicare NSC