Samuel Porter Jacks, MD

Primary specialty

Thoracic Surgery (Cardiothoracic Vascular Surgery) PhysicianTaxonomy code 208G00000X

License

2015-01953 Issued in NC

Practice address

4622 Country Club Rd
Suite 180
Winston Salem, NC 27104-3769

Phone

(336) 768-9535

Fax

(336) 768-4155

NPI assigned

Jun 13, 2007

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 3

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in NC

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Thoracic SurgeryAlso: General Surgery

Education

Wake Forest University School of Medicine, 2004

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Novant Health Medical Group, LLCGroup PAC ID 1153234893, 2,413 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Novant Health Forsyth Medical Center Hospital, Winston-Salem, NC, CCN 340014
• Novant Health Medical Park Hospital Hospital, Winston-Salem, NC, CCN 340148

Procedures performed for Medicare patients

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Novant Health Medical Group, LLC

  • Neurology with Special Qualifications in Child Neurology Physician
  • Charlotte, NC
  • NPI 1366409492
  Medicare reassignment Care Compare group NPD
• Novant Health Thomasville Medical Center, LLC

  • Specialist
  • Thomasville, NC
  • NPI 1033160205
  Medicare reassignment NPD
• Novant Health Medical Group, LLC

  • Obstetrics & Gynecology Physician
  • Matthews, NC
  • NPI 1386506137
  NPD
• Novant Health Medical Group, LLC

  • Obstetrics & Gynecology Physician
  • Charlotte, NC
  • NPI 1538400890
  NPD
• Novant Health Thomasville Medical Center LLC

  • Hematology & Oncology Physician
  • Winston Salem, NC
  • NPI 1649159609
  NPD
• Novant Health Thomasville Medical Center, LLC

  • Hematology & Oncology Physician
  • Winston Salem, NC
  • NPI 1952056087
  NPD
• Novant Health Medical Group, LLC

  • Internal Medicine Physician
  • Charlotte, NC
  • NPI 1134841802
  NPD (past)

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Forsyth Memorial Hospital, Inc.

  • General Acute Care Hospital
  • Winston Salem, NC
  • NPI 1447200233
  Care Compare affiliation
• Medical Park Hospital LLC

  • General Acute Care Hospital
  • Winston-Salem, NC
  • NPI 1538111828
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1181692800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1603584000000",
    "number": "1184828030",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 60447",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282600447",
            "telephone_number": "336-768-9535",
            "fax_number": "336-768-4155"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4622 COUNTRY CLUB RD",
            "address_2": "SUITE 180",
            "city": "WINSTON SALEM",
            "state": "NC",
            "postal_code": "271043769",
            "telephone_number": "336-768-9535",
            "fax_number": "336-768-4155"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKS",
        "first_name": "SAMUEL",
        "middle_name": "PORTER",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-06-13",
        "last_updated": "2020-10-25",
        "certification_date": "2020-09-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "NC",
            "license": "2015-01953",
            "primary": false
        },
        {
            "code": "208G00000X",
            "taxonomy_group": "",
            "desc": "Thoracic Surgery (Cardiothoracic Vascular Surgery)",
            "state": "NC",
            "license": "2015-01953",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "005979900",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003125978A",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD  MEDICARE",
            "identifier": "P01084809",
            "state": "FL"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "sjacks259781@direct.novanthealth.org",
            "affiliation": "N",
            "address_1": "4622 Country Club Rd",
            "address_2": "Suite 180",
            "city": "Winston Salem",
            "state": "NC",
            "country_code": "US",
            "postal_code": "271043769",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Marwa Jaafar
• Abdur Rahman Jabir
• Sara Elizabeth Jackowicz, PA-C
• Jasmine S Jackowski, PT, DPT
• Demetria Ileana Strauch Jacks, MD
• Robin Denise Jackson-Creef, PA
• Ashley S Jackson
• Brittany Shavon Jackson, MD
• Campbell Gray Jackson
• David Stone Jackson Jr., MD

• Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician in Winston Salem, NC
• Providers in Winston Salem, NC by specialty
• Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 25, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.