Healthcare Provider Details

I. General information

NPI: 1497033500
Provider Name (Legal Business Name): JACKSON MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2011
Last Update Date: 07/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 NW 10TH AVE SUITE 2054A
MIAMI FL
33136-1011
US

IV. Provider business mailing address

1450 NW 10TH AVE SUITE 2054A
MIAMI FL
33136-1011
US

V. Phone/Fax

Practice location:
  • Phone: 917-536-1624
  • Fax:
Mailing address:
  • Phone: 917-536-1624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code281P00000X
TaxonomyChronic Disease Hospital
License Number
License Number State

VIII. Authorized Official

Name: EVIS HARJA
Title or Position: FWLLOW
Credential: MD
Phone: 917-536-1634