Healthcare Provider Details

I. General information

NPI: 1407801194
Provider Name (Legal Business Name): ER PHYSICIAN GROUP AT JACKSON HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 HOSPITAL DR
MARIANNA FL
32446-1917
US

IV. Provider business mailing address

4250 HOSPITAL DR
MARIANNA FL
32446-1917
US

V. Phone/Fax

Practice location:
  • Phone: 850-526-2200
  • Fax: 850-718-2649
Mailing address:
  • Phone: 850-526-2200
  • Fax: 850-718-2649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code282NR1301X
TaxonomyRural Acute Care Hospital
License Number3999
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. KELLY CONNOLLY
Title or Position: CFO
Credential:
Phone: 850-718-2623