Provider Demographics
NPI:1649267618
Name:ROSWELL CLINIC CORP
Entity type:Organization
Organization Name:ROSWELL CLINIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR, ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-892-9815
Mailing Address - Street 1:4000 MERIDIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-6325
Mailing Address - Country:US
Mailing Address - Phone:615-465-7000
Mailing Address - Fax:615-628-6877
Practice Address - Street 1:350 W COUNTRY CLUB RD
Practice Address - Street 2:STE 201
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5205
Practice Address - Country:US
Practice Address - Phone:888-801-5554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROSWELL CLINIC CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-04
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 207RC0000X, 207RP1001X, 207RS0012X, 207V00000X, 207X00000X, 208600000X
NM207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM60806516Medicaid
NMDD5451OtherRR MEDICARE
NMDA5509OtherRR MEDICARE
NMNPI AND TINOtherBCBS
NMDD5451OtherRR MEDICARE