Healthcare Provider Details

I. General information

NPI: 1831225465
Provider Name (Legal Business Name): JACKSON ENT CLINIC , PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 11/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 HIGHWAY 15 S STE 29
JACKSON KY
41339-9221
US

IV. Provider business mailing address

PO BOX 768
JACKSON KY
41339-0768
US

V. Phone/Fax

Practice location:
  • Phone: 606-666-9909
  • Fax: 606-666-9982
Mailing address:
  • Phone: 606-666-9909
  • Fax: 606-666-9982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number36227
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number36227
License Number StateKY

VIII. Authorized Official

Name: DR. TARIQ A SARTAWI
Title or Position: OWNER
Credential: M.D.
Phone: 606-666-9909