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General NPI Number Information
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NPI Number | 1346388576
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Entity Type | Organization
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Legal Business Name | JACKSON PARK PHYSICIANS, PC
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Dates
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Enumeration Date | 02/01/2007
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Last Update Date | 06/25/2013
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Provider Practice Location Address
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Address Line | 1124 MEDICAL PLACE
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City | SEYMOUR
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State | IN
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Zip | 47274
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Country | US
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Telephone | 812-522-1613
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Fax | 812-522-6694
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Provider Business Mailing Address
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Address Line | 1124 MEDICAL PLACE
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City | SEYMOUR
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State | IN
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Zip | 47274
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Country | US
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Telephone | 812-522-1613
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Fax | 812-522-6694
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MRS. KELLEY M GILLASPY
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Credential |
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Telephone | 812-522-1613
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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 | 50000714A
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License Number State | IN
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