Provider Demographics
NPI:1457432460
Name:JACKSON COUNTY HOSPITAL DISTRICT
Entity type:Organization
Organization Name:JACKSON COUNTY HOSPITAL DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINSITRATOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ASA
Authorized Official - Middle Name:B
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-782-7810
Mailing Address - Street 1:1013 S WELLS ST
Mailing Address - Street 2:
Mailing Address - City:EDNA
Mailing Address - State:TX
Mailing Address - Zip Code:77957-4098
Mailing Address - Country:US
Mailing Address - Phone:361-782-7800
Mailing Address - Fax:361-782-7495
Practice Address - Street 1:1013 S WELLS ST
Practice Address - Street 2:
Practice Address - City:EDNA
Practice Address - State:TX
Practice Address - Zip Code:77957-4098
Practice Address - Country:US
Practice Address - Phone:361-782-7800
Practice Address - Fax:361-782-7495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00U54JOtherBLUE CROSS
TX111714501Medicaid
TX00U54JMedicare PIN
TX00U54JOtherBLUE CROSS