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General NPI Number Information
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NPI Number | 1790732881
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Entity Type | Organization
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Legal Business Name | ER PHYSICIAN GROUP AT JACKSON HOSPITAL
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Dates
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Enumeration Date | 05/27/2006
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Last Update Date | 08/13/2008
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Provider Practice Location Address
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Address Line | 4298 5TH AVE
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City | MARIANNA
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State | FL
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Zip | 32446-2173
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Country | US
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Telephone | 850-482-5787
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Fax | 850-482-8108
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Provider Business Mailing Address
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Address Line | 4298 5TH AVE
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City | MARIANNA
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State | FL
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Zip | 32446-2173
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Country | US
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Telephone | 850-482-5787
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Fax | 850-482-8108
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Authorized Official
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Title or Position | ACCOUNTS MANAGER
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Name | MS. JOYCE Y. AL-MATEEN
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Credential |
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Telephone | 850-482-5787
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 3999
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License Number State | FL
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