Basic Information
| Provider Information | |||||||||
| NPI: | 1912931189 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSON MADISON COUNTY GENERAL HOSPITAL | ||||||||
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| OtherOrganizationName: | BRADFORD FAMILY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1804 HIGHWAY 45 BYP | ||||||||
| Address2: | SUITE 604 | ||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383054436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316608759 | ||||||||
| FaxNumber: | 7316608739 | ||||||||
| Practice Location | |||||||||
| Address1: | 216 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRADFORD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383168651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7317422241 | ||||||||
| FaxNumber: | 7317423935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 05/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | JAMA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR PHYSICIAN BILLING | ||||||||
| AuthorizedOfficialTelephone: | 7315121510 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JACKSON MADISON COUNTY GENERAL HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine | 207QA0505X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207QG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RA0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Adolescent Medicine | 207RG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.