Provider Demographics
NPI:1851354245
Name:JACKSON, ELMER H (MD)
Entity Type:Individual
Prefix:
First Name:ELMER
Middle Name:H
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3361
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42564-3361
Mailing Address - Country:US
Mailing Address - Phone:865-766-8818
Mailing Address - Fax:865-766-8825
Practice Address - Street 1:217 S 3RD ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1823
Practice Address - Country:US
Practice Address - Phone:859-239-1220
Practice Address - Fax:859-239-6719
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY152662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000063422OtherBCBS GROUP
KY64152663Medicaid
KY0651703Medicare PIN
KY0687503Medicare PIN
KY300017784Medicare PIN
KY0037002Medicare PIN
KYC64717Medicare UPIN