MEDICARE: JACKSON HOSPITAL AND CLINIC INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician

General Provider Information

NPI Number	:	1053844654
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON HOSPITAL AND CLINIC INC.

Provider Business Mailing Address
First Line	:	1722 PINE ST
Second Line	:	SUITE 503
City	:	MONTGOMERY
State	:	AL
Zip	:	36106-1103
Country	:	US
Telephone Number	:	334-293-8736
Fax Number	:	334-293-8738

Provider Business Practice Location Address
First Line	:	515 HOSPITAL DR
Second Line	:	SUITE A
City	:	WETUMPKA
State	:	AL
Zip	:	36092-1626
Country	:	US
Telephone Number	:	334-293-8588
Fax Number	:	334-293-6978

Authorized Official
Title or Position	:	REVENUE CYCLE DIRECTOR
Name	:	TARA HERRING
Credential	:
Telephone Number	:	334-240-2337

Provider Enumeration Date	:	04/10/2017
Last Update Date	:	04/10/2017

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