Provider Demographics
NPI:1558412023
Name:STATESBORO HMA PHYSICIAN MANAGEMENT LLC
Entity Type:Organization
Organization Name:STATESBORO HMA PHYSICIAN MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR DUR PROV ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7000
Mailing Address - Street 1:4000 MERIDIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-6325
Mailing Address - Country:US
Mailing Address - Phone:615-465-7000
Mailing Address - Fax:
Practice Address - Street 1:1499 FAIR RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1683
Practice Address - Country:US
Practice Address - Phone:912-871-5437
Practice Address - Fax:912-871-8595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-13
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGP 366354327AMedicaid
GAGRP 8047Medicare PIN