Basic Information
| Provider Information | |||||||||
| NPI: | 1184828030 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKS | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | PORTER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367689535 | ||||||||
| FaxNumber: | 3367684155 | ||||||||
| Practice Location | |||||||||
| Address1: | 4622 COUNTRY CLUB RD | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271043769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367689535 | ||||||||
| FaxNumber: | 3367684155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 10/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 2015-01953 | NC | N | Allopathic & Osteopathic Physicians | Surgery | 208G00000X | 2015-01953 | NC | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 005979900 | 05 | FL | MEDICAID | 003125978A | 05 | GA | MEDICAID | P01084809 | 01 | FL | RAILROAD MEDICARE | OTHER |