MEDICARE: R. ELLIOTT JACKSON GERIATRICS,LLC

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	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	047774	GA

General Provider Information

NPI Number	:	1437261617
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	R. ELLIOTT JACKSON GERIATRICS,LLC

Provider Business Mailing Address
First Line	:	3904 N DRUID HILLS RD
Second Line	:	#222
City	:	DECATUR
State	:	GA
Zip	:	30033-3105
Country	:	US
Telephone Number	:	770-458-1594
Fax Number	:	770-458-1596

Provider Business Practice Location Address
First Line	:	2650 WEIGELIA RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30345-3969
Country	:	US
Telephone Number	:	404-213-3672
Fax Number	:	770-458-1596

Authorized Official
Title or Position	:	OWNER
Name	:	RAMSEY ELLIOTT JACKSON
Credential	:	M.D.
Telephone Number	:	404-213-3672

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	08/22/2020

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