Basic Information
| Provider Information | |||||||||
| NPI: | 1225705759 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KEY WEST HMA PHYSICIAN MANAGEMENT LLC | ||||||||
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| OtherOrganizationName: | KEY WEST HMA PHYSICIAN MANAGEMENT LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 689022 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370689022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154657211 | ||||||||
| FaxNumber: | 6156286877 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 12TH ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | KEY WEST | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330403001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052925823 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2021 | ||||||||
| LastUpdateDate: | 03/16/2022 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. DR PROV ENROLLMENT & ONBOARDING | ||||||||
| AuthorizedOfficialTelephone: | 6154653334 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RI0011X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207XX0801X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207Y00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 363LA2100X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 207RC0000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | FL | MEDICAID |