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	2086S0129X	Vascular Surgery Physician

General Provider Information

NPI Number	:	1740657683
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	:	334-240-2337
Fax Number	:	334-293-6859

Provider Business Practice Location Address
First Line	:	44 MEDICAL ARTS CT
Second Line	:
City	:	GREENVILLE
State	:	AL
Zip	:	36037-3869
Country	:	US
Telephone Number	:	334-293-8922
Fax Number	:	334-293-6820

Authorized Official
Title or Position	:	ADMINISTRATOR JACKSON CLINIC
Name	:	MS. KELIN PENNEY
Credential	:
Telephone Number	:	334-240-2335

Provider Enumeration Date	:	08/26/2015
Last Update Date	:	08/26/2015

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