Healthcare Provider Details

I. General information

NPI: 1154646966
Provider Name (Legal Business Name): JACKSON HOSPITAL AND CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2010
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 PINE ST
MONTGOMERY AL
36106-1109
US

IV. Provider business mailing address

1725 PINE ST
MONTGOMERY AL
36106-1109
US

V. Phone/Fax

Practice location:
  • Phone: 334-293-8000
  • Fax:
Mailing address:
  • Phone: 334-293-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. RICHARD F. MANN
Title or Position: DIRECTOR OF REVENUE CYCLE
Credential:
Phone: 334-293-8112