Basic Information
| Provider Information | |||||||||
| NPI: | 1679774996 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSON HOSPITAL CORPORATION | ||||||||
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| OtherOrganizationName: | KENTUCKY RIVER ER, ANESTH, RADIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 540 JETT DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 413399622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066666000 | ||||||||
| FaxNumber: | 6066666107 | ||||||||
| Practice Location | |||||||||
| Address1: | 540 JETT DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 413399622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066666000 | ||||||||
| FaxNumber: | 6066666107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 06/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8778929813 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JACKSON HOSPITAL CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65938276 | 05 | KY | MEDICAID | 74900580 | 05 | KY | MEDICAID |