Provider Demographics
NPI:1821141219
Name:WILLIAM G JACKSON, M.D., LLC
Entity Type:Organization
Organization Name:WILLIAM G JACKSON, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-462-3009
Mailing Address - Street 1:46 TOLL RD
Mailing Address - Street 2:UNIT B
Mailing Address - City:SALISBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01952-1435
Mailing Address - Country:US
Mailing Address - Phone:978-462-3009
Mailing Address - Fax:978-462-0177
Practice Address - Street 1:46 TOLL RD
Practice Address - Street 2:UNIT B
Practice Address - City:SALISBURY
Practice Address - State:MA
Practice Address - Zip Code:01952-1435
Practice Address - Country:US
Practice Address - Phone:978-462-3009
Practice Address - Fax:978-462-0177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2013-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57551207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9751301Medicaid
MAM18969OtherBCBS
NH30213523Medicaid
MAM21678Medicare ID - Type Unspecified