Basic Information
| Provider Information | |||||||||
| NPI: | 1972674851 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JELLICO COMMUNITY HOSPITAL INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JELLICO COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 844869 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237841334 | ||||||||
| FaxNumber: | 4237841336 | ||||||||
| Practice Location | |||||||||
| Address1: | 188 HOSPITAL LAN | ||||||||
| Address2: | |||||||||
| City: | JELLICO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377624400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237841334 | ||||||||
| FaxNumber: | 4237841136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 06/07/2016 | ||||||||
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| AuthorizedOfficialLastName: | GHULAM | ||||||||
| AuthorizedOfficialFirstName: | EVELYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 4237841334 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.