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General NPI Number Information
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NPI Number | 1164745782
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Entity Type | Organization
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Legal Business Name | MICHAEL S. JACKSON, MD, PC
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Dates
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Enumeration Date | 03/10/2010
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Last Update Date | 01/20/2011
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Provider Practice Location Address
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Address Line | 701 E 2ND AVE SW SUITE C
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City | ROME
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State | GA
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Zip | 30161-6148
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Country | US
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Telephone | 706-266-9090
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Fax | 706-204-8797
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Provider Business Mailing Address
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Address Line | PO BOX 40
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City | SILVER CREEK
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State | GA
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Zip | 30173-0040
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Country | US
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Telephone | 706-266-9090
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Fax | 706-204-8797
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL S JACKSON
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Credential | MD
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Telephone | 706-266-9090
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 055376
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License Number State | GA
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