Basic Information
Provider Information | |||||||||
NPI: | 1992748693 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JACKSON COUNTY HOSPITAL DISTRICT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | JACKSON MEDICAL CLINIC OF EDNA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1013 S WELLS STREET | ||||||||
Address2: |   | ||||||||
City: | EDNA | ||||||||
State: | TX | ||||||||
PostalCode: | 779574098 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3617827800 | ||||||||
FaxNumber: | 3617827495 | ||||||||
Practice Location | |||||||||
Address1: | 1013A SOUTH WELLS STREET | ||||||||
Address2: |   | ||||||||
City: | EDNA | ||||||||
State: | TX | ||||||||
PostalCode: | 779574045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3617823560 | ||||||||
FaxNumber: | 3617825627 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2006 | ||||||||
LastUpdateDate: | 05/09/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SMIGA | ||||||||
AuthorizedOfficialFirstName: | LANCE | ||||||||
AuthorizedOfficialMiddleName: | HARRISON | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR/CFO | ||||||||
AuthorizedOfficialTelephone: | 3617827800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 063595501 | 05 | TX |   | MEDICAID |