Provider Demographics
NPI:1932154713
Name:JACKSON SURGICAL ASSOCIATES. PA
Entity Type:Organization
Organization Name:JACKSON SURGICAL ASSOCIATES. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-664-7395
Mailing Address - Street 1:395 HOSPITAL BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2080
Mailing Address - Country:US
Mailing Address - Phone:731-664-7395
Mailing Address - Fax:731-664-0057
Practice Address - Street 1:395 HOSPITAL BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2080
Practice Address - Country:US
Practice Address - Phone:731-664-7395
Practice Address - Fax:731-664-0057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9997208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN107276OtherBLUE CROSS
TN3053968Medicaid
TN4005486OtherBLUE CROSS
TN1609871821OtherNPI
TN1356346142OtherNPI
TN3060477OtherBLUE CROSS
TN1376548503OtherNPI
TN3089277Medicaid
TN3862742Medicaid
TNE50713Medicare UPIN
TN3862742Medicare PIN
TN4005486OtherBLUE CROSS
TNH34225Medicare UPIN
TN3089279Medicare PIN
TN107276OtherBLUE CROSS