Healthcare Provider Details

I. General information

NPI: 1356917892
Provider Name (Legal Business Name): ER PHYSICIAN GROUP AT JACKSON HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 01/16/2023
Certification Date: 01/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1798 GEORGIA ST
ALFORD FL
32420-6800
US

IV. Provider business mailing address

4250 HOSPITAL DR
MARIANNA FL
32446-1917
US

V. Phone/Fax

Practice location:
  • Phone: 850-526-6727
  • Fax: 850-526-1027
Mailing address:
  • Phone: 850-526-6727
  • Fax: 850-526-1027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MARGARET CARTER
Title or Position: PAYER CREDENTIALING COORDINATOR
Credential:
Phone: 850-718-2531