Provider Demographics
NPI:1538108725
Name:JACKSON COUNTY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:JACKSON COUNTY HOSPITAL DISTRICT
Other - Org Name:JACKSON HOSPITAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-718-2623
Mailing Address - Street 1:4250 HOSPITAL DR
Mailing Address - Street 2:PO BOX 1608
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-1917
Mailing Address - Country:US
Mailing Address - Phone:850-526-2200
Mailing Address - Fax:850-718-2649
Practice Address - Street 1:4250 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-1917
Practice Address - Country:US
Practice Address - Phone:850-526-2200
Practice Address - Fax:850-718-2649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010106100Medicaid
FL100142Medicare ID - Type Unspecified
FL010106100Medicaid
FL103866Medicare Oscar/Certification