Basic Information
| Provider Information | |||||||||
| NPI: | 1083171664 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JELLICO MEDICAL CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 188 HOSPITAL LN | ||||||||
| Address2: | |||||||||
| City: | JELLICO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377624400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237847252 | ||||||||
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| Practice Location | |||||||||
| Address1: | 188 HOSPITAL LN | ||||||||
| Address2: | |||||||||
| City: | JELLICO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377624400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237847252 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2019 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | LEFTWICH | ||||||||
| AuthorizedOfficialFirstName: | HAL | ||||||||
| AuthorizedOfficialMiddleName: | WEST | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4237847252 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DBA, FACHE | ||||||||
| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
No ID Information.