Basic Information
| Provider Information | |||||||||
| NPI: | 1174773428 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERNAL MEDICINE CLINIC OF JACKSON PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 WINDWOOD DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383058835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316689031 | ||||||||
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| Practice Location | |||||||||
| Address1: | 587 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314248922 | ||||||||
| FaxNumber: | 7314232922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2008 | ||||||||
| LastUpdateDate: | 09/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | DUNNEBACKE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | HUDSON | ||||||||
| AuthorizedOfficialTitleorPosition: | PLLC MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 7316689031 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D, | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | MD011299 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 3182200 | 05 | TN | MEDICAID |