Provider Demographics
NPI:1790732881
Name:ER PHYSICIAN GROUP AT JACKSON HOSPITAL
Entity Type:Organization
Organization Name:ER PHYSICIAN GROUP AT JACKSON HOSPITAL
Other - Org Name:WOMEN'S HEALTHCARE OF THE PANHANDLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNTS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:Y
Authorized Official - Last Name:AL-MATEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-482-5787
Mailing Address - Street 1:4298 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-2173
Mailing Address - Country:US
Mailing Address - Phone:850-482-5787
Mailing Address - Fax:850-482-8108
Practice Address - Street 1:4298 5TH AVE
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2173
Practice Address - Country:US
Practice Address - Phone:850-482-5787
Practice Address - Fax:850-482-8108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3999174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty