Provider Demographics
NPI:1639314230
Name:JACKSON HOSPITAL AND CLINIC, INC
Entity Type:Organization
Organization Name:JACKSON HOSPITAL AND CLINIC, INC
Other - Org Name:JACKSON CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:VERRECCHIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-293-8000
Mailing Address - Street 1:1722 PINE ST
Mailing Address - Street 2:STE 503
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1103
Mailing Address - Country:US
Mailing Address - Phone:334-270-9914
Mailing Address - Fax:
Practice Address - Street 1:1801 PINE ST
Practice Address - Street 2:SUITE 301
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-0165
Practice Address - Country:US
Practice Address - Phone:334-293-5778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALH283Medicare PIN