Basic Information
| Provider Information | |||||||||
| NPI: | 1467493916 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSON MADISON COUNTY GENERAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 505342 | ||||||||
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| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631505342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316608730 | ||||||||
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| Practice Location | |||||||||
| Address1: | 620 SKYLINE DR | ||||||||
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| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316608730 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 10/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7315416735 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JACKSON MADISON COUNTY GENERAL HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2080N0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 207RI0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 3280146 | 05 | TN | MEDICAID |