Basic Information
| Provider Information | |||||||||
| NPI: | 1083950414 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JACKSON HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BEATTYVILLE FAMILY MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 689022 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370689022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007097338 | ||||||||
| FaxNumber: | 6154696505 | ||||||||
| Practice Location | |||||||||
| Address1: | 1027 HIGHWAY 11 N | ||||||||
| Address2: | |||||||||
| City: | BEATTYVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 413119240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064640061 | ||||||||
| FaxNumber: | 6064640420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2012 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COOPER | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP FINANCE OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6152213840 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JACKSON HOSPITAL CORPORATION | ||||||||
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| NPICertificationDate: | 09/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 100620 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.