| NPI | 1497153522 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JENNIFER L JACKSON Sr. Director Provider Enrollment 877-848-1457 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine |
| Additional Taxonomies | 207W00000X Ophthalmology |
| 208000000X Pediatrics | |
| 208600000X Surgery | |
| 208800000X Urology | |
| 213E00000X Podiatrist | |
| 213ES0103X Podiatrist, Foot & Ankle Surgery | |
| 363LF0000X Nurse Practitioner, Family | |
| 363LP0200X Nurse Practitioner, Pediatrics | |
| 207RR0500X Internal Medicine, Rheumatology | |
| 207V00000X Obstetrics & Gynecology | |
| 1223G0001X Dentist, General Practice | |
| 207Q00000X Family Medicine | |
| 207RC0000X Internal Medicine, Cardiovascular Disease | |
| 207RP1001X Internal Medicine, Pulmonary Disease | |
| Enumeration Date | 2014-12-05 |
| Last Update Date | 2020-09-24 |