Basic Information
| Provider Information | |||||||||
| NPI: | 1093705428 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JACKSON MADISON COUNTY GENERAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 SKYLINE DRIVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315415000 | ||||||||
| FaxNumber: | 7316608739 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315415000 | ||||||||
| FaxNumber: | 7316608739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERIM PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 7315415000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0000000078 | TN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0440002 | 05 | TN | MEDICAID |