Provider Demographics
NPI:1770566986
Name:JACKSON UROLOGICAL ASSOCIATES, P.C.
Entity type:Organization
Organization Name:JACKSON UROLOGICAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:HELEN
Authorized Official - Last Name:CEPPARULO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-427-9971
Mailing Address - Street 1:PO BOX 1446
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38025-1446
Mailing Address - Country:US
Mailing Address - Phone:731-427-9971
Mailing Address - Fax:731-424-2052
Practice Address - Street 1:28 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3947
Practice Address - Country:US
Practice Address - Phone:731-427-9971
Practice Address - Fax:731-424-2052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-22
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0142333OtherBLUE CROSS BLUE SHIELD
TN3704374Medicaid
TN3704974Medicare ID - Type Unspecified
TN3704374Medicaid
TNCL9420Medicare ID - Type UnspecifiedRAILROAD MEDICARE