Provider Demographics
NPI:1972655314
Name:JACKSON CLINIC UROLOGY-DR NEWMAN
Entity Type:Organization
Organization Name:JACKSON CLINIC UROLOGY-DR NEWMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:334-293-8000
Mailing Address - Street 1:1725 PINE STREET
Mailing Address - Street 2:ATTN: PATIENT FINANCIAL SERVICES
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1109
Mailing Address - Country:US
Mailing Address - Phone:334-293-8736
Mailing Address - Fax:334-293-8738
Practice Address - Street 1:1722 PINE STREET
Practice Address - Street 2:SUITE 903
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1158
Practice Address - Country:US
Practice Address - Phone:334-265-6933
Practice Address - Fax:334-265-7415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8045208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL010003281OtherTRAVLERS RAILROAD
AL82994OtherBLUE CROSS
AL000082994Medicaid