Healthcare Provider Details

I. General information

NPI: 1164745782
Provider Name (Legal Business Name): MICHAEL S. JACKSON, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2010
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E 2ND AVE SW SUITE C
ROME GA
30161-6148
US

IV. Provider business mailing address

PO BOX 40
SILVER CREEK GA
30173-0040
US

V. Phone/Fax

Practice location:
  • Phone: 706-266-9090
  • Fax: 706-204-8797
Mailing address:
  • Phone: 706-266-9090
  • Fax: 706-204-8797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number055376
License Number StateGA

VIII. Authorized Official

Name: DR. MICHAEL S JACKSON
Title or Position: PRESIDENT
Credential: MD
Phone: 706-266-9090