Basic Information
| Provider Information | |||||||||
| NPI: | 1164480893 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOSPITALISTS OF JACKSON LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 534255 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303534255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005141494 | ||||||||
| FaxNumber: | 9048051456 | ||||||||
| Practice Location | |||||||||
| Address1: | 367 HOSPITAL BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383052080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316612185 | ||||||||
| FaxNumber: | 7316612187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 08/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | BUNKER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN/PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9048051300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3727496 | 05 | TN | MEDICAID |