MEDICARE: DR. WILLIAM THOMAS 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	207X00000X	Orthopaedic Surgery Physician	2002-01368	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700868106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIAM THOMAS JACKSON M.D.

Provider Business Mailing Address
First Line	:	P.O. BOX 1350
Second Line	:
City	:	MOORESVILLE
State	:	NC
Zip	:	28115-1350
Country	:	US
Telephone Number	:	704-799-3380
Fax Number	:	704-799-6315

Provider Business Practice Location Address
First Line	:	131 MEDICAL PARK ROAD
Second Line	:	SUITE 204
City	:	MOORESVILLE
State	:	NC
Zip	:	28117-8524
Country	:	US
Telephone Number	:	704-664-5633
Fax Number	:	704-664-5631

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

Provider Enumeration Date	:	11/19/2005
Last Update Date	:	07/30/2008

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