=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295490878
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROOKSVILLE HMA PHYSICIAN MANAGEMENT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2021
-----------------------------------------------------
Last Update Date | 03/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8425 NORTHCLIFFE BLVD STE 106
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34606-1107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-544-6145
-----------------------------------------------------
Fax | 877-892-9815
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 689022
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37068-9022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-465-7211
-----------------------------------------------------
Fax | 615-628-6877
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR DIR PROV ENROLLMENT & ONBOARDING
-----------------------------------------------------
Name | JENNIFER L JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-465-3334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------