Provider Demographics
NPI:1922196062
Name:JACKSON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:JACKSON MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF CRNA
Authorized Official - Prefix:MR
Authorized Official - First Name:GILBERTO
Authorized Official - Middle Name:AGUSTINE
Authorized Official - Last Name:SOTO
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:305-996-0025
Mailing Address - Street 1:3311 SW 17TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-1821
Mailing Address - Country:US
Mailing Address - Phone:304-448-7294
Mailing Address - Fax:
Practice Address - Street 1:3311 SW 17TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-1821
Practice Address - Country:US
Practice Address - Phone:304-448-7294
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2738382282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access