Healthcare Provider Details

I. General information

NPI: 1649267618
Provider Name (Legal Business Name): ROSWELL CLINIC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W COUNTRY CLUB RD STE 201
ROSWELL NM
88201-5205
US

IV. Provider business mailing address

4000 MERIDIAN BLVD
FRANKLIN TN
37067-6325
US

V. Phone/Fax

Practice location:
  • Phone: 888-801-5554
  • Fax:
Mailing address:
  • Phone: 615-465-7000
  • Fax: 615-628-6877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER L JACKSON
Title or Position: SENIOR DIRECTOR, ENROLLMENT
Credential:
Phone: 877-892-9815