MEDICARE: DR. EDWARD A JACKSON M.D.

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	207Q00000X	Family Medicine Physician	4301046128	MI
2	207Q00000X	Family Medicine Physician	ME129390	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
10	0G37620004	OTHER	MI	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	101977	OTHER	MI	GREAT LAKES HEALTH PLAN
2	381870664	OTHER	MI	PRIORITY HEALTH
3	381870664	OTHER	MI	PRIVATE HEALTHCARE SYSTE
4	381870664112	OTHER	MI	COMMUNITY CHOICE MICHIGAN
5	0730985	OTHER	MI	BCBSM PIN
6	381870664	OTHER	MI	PPOM
7	080G376200	OTHER	MI	BCBSM GROUP NUMBER
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	EJ046128	OTHER	MI	LICENSE
11	381870664	OTHER	MI	HEALTH CARE ALLIANCE POOL
12	4045995	OTHER	MI	AETNA
13	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639104029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWARD A JACKSON M.D.

Provider Business Mailing Address
First Line	:	7975 LAKE UNDERHILL RD STE 200
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32822-8204
Country	:	US
Telephone Number	:	407-303-6830
Fax Number	:	407-303-8659

Provider Business Practice Location Address
First Line	:	7975 LAKE UNDERHILL RD STE 200
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32822-8204
Country	:	US
Telephone Number	:	407-303-6830
Fax Number	:	407-303-8659

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	07/21/2022

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