Provider Demographics
NPI:1558506550
Name:GADSDEN REGIONAL PHYSICIAN GROUP PRACTICE LLC
Entity Type:Organization
Organization Name:GADSDEN REGIONAL PHYSICIAN GROUP PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR DIR PROV ENROLLMENT & ONBOARDING
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:615-465-3334
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:615-465-3334
Mailing Address - Fax:615-628-6877
Practice Address - Street 1:100 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 308
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35903-1134
Practice Address - Country:US
Practice Address - Phone:256-494-4646
Practice Address - Fax:256-494-4649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-05
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1558506550/109105Medicaid
AL510G700524Medicare PIN