NPIMap

Jackson Clinic Multispecialty Wetumpka

Organization Active NPI Specialist · Wetumpka, AL

NPI 1295351963 · NPPES record last updated Jun 18, 2020

Key facts

NPI
1295351963
Entity type
Organization (NPI type 2)
Primary specialty
Specialist 174400000X
Legal business name
JACKSON CLINIC MULTISPECIALTY WETUMPKA
Practice address
277 Huntress St
Wetumpka, AL 36092-3329
Phone
(334) 293-8736
Fax
(334) 293-8738
NPI assigned
Jun 18, 2020
Organization subpart
No

Authorized official

Name
Tara Herring
Title
Revenue Cycle Director
Phone
(334) 240-2337

Corporate family (same tax ID) 24

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Medicare participation

Medicare fee-for-service enrollment
Enrolled in AL

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20040414000971 AL Part B Supplier - Clinic/Group Practice 0547254153 Receives reassigned benefits from 247 practitioners
This NPI is an additional NPI on the enrollment

National Provider Directory

Tax ID family
Egidio G Delfabbro (71 organizations share this tax ID)

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Specialist
Group: 193200000X MULTI-SPECIALTY GROUP		 174400000X Yes

Addresses

Primary practice location

277 Huntress St
Wetumpka, AL 36092-3329

Mailing address

1722 Pine St Ste 203
Montgomery, AL 36106-1158
Phone (334) 293-8736

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Jun 18, 2020.

{
    "created_epoch": "1592438400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1592438400000",
    "number": "1295351963",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1722 PINE ST STE 203",
            "city": "MONTGOMERY",
            "state": "AL",
            "postal_code": "361061158",
            "telephone_number": "334-293-8736",
            "fax_number": "334-293-8738"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "277 HUNTRESS ST",
            "city": "WETUMPKA",
            "state": "AL",
            "postal_code": "360923329",
            "telephone_number": "334-293-8736",
            "fax_number": "334-293-8738"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JACKSON CLINIC MULTISPECIALTY WETUMPKA",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-06-18",
        "last_updated": "2020-06-18",
        "certification_date": "2020-06-18",
        "status": "A",
        "authorized_official_last_name": "HERRING",
        "authorized_official_first_name": "TARA",
        "authorized_official_title_or_position": "REVENUE CYCLE DIRECTOR",
        "authorized_official_telephone_number": "334-240-2337"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Specialist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Wetumpka, AL

All providers in Wetumpka, AL · Specialist in Alabama

Sources for this page

Verify at the official NPI Registry.