NPIMap

Organization Active NPI

Jacksonville Hospital LLC

  • Rural Health Clinic/Center
  • Jacksonville, TX
National Provider Identifier
1861991226
Registry record updated Oct 1, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
JACKSONVILLE HOSPITAL LLC
Practice address
203 Nacogdoches St Ste 280
Jacksonville, TX 75766-2444
Phone
(903) 541-5396
Fax
(903) 591-5393
NPI assigned
Feb 12, 2018
Last updated
Oct 1, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
AHS EAST TEXAS HEALTH SYSTEM, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 1, 2023

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

Authorized official

Name
Stephen C Petrovich
Title
Evp
Phone
(615) 296-3000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

203 Nacogdoches St Ste 280
Jacksonville, TX 75766-2444

Mailing address

340 Seven Springs Way Ste 100
Brentwood, TN 37027-5697
Phone (615) 296-3000

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180502001139 TX Part A Provider - Rural Health Clinic 4284996638 Practice locations: Jacksonville, TX

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1861991226. Details of each certification follow.

Rural health clinic certification: CCN 673400

Legal name
JACKSONVILLE HOSPITAL LLC
Doing business as
UT HEALTH EAST TEXAS JACKSONVILLE PHYSICIAN CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 28, 2012
Last certification
Jun 25, 2019
Ownership / control type
1B
Most recent change of ownership
Mar 1, 2018 (1 total)
Organization structure
LLCProprietary
Incorporated
Dec 19, 2017 in DE
Enrollment address
203 Nacogdoches St
Ste 280
Jacksonville, TX 75766-2444
Related CCNs
450194

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
45D1095752Jacksonville Hospital, LLC203 Nacogdoches Suite 280, Jacksonville, TX 75766Certificate of waiverOct 30, 2026

National Provider Directory

National Provider Directory
Tax ID family
Jacksonville Hospital LLC4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

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

Locations

1 Burton Hills Blvd
Ste 250
Nashville, TN 37215
Phone (615) 296-3000

203 Nacogdoches St
Ste 220
Jacksonville, TX 75766
Phone (903) 339-3035

Ownership & related parties

All disclosed owners & managing parties 15

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Ardent Health Inc Organization, Brentwood, TN LLC 5% Or Greater Indirect Ownership Interest Mar 1, 2018 100%
Brian Walton Individual Corporate Officer Mar 1, 2018
Ahs Texas, LLC Organization, Brentwood, TN LLC 5% Or Greater Indirect Ownership Interest Jan 1, 2019 100%
Carolyn Schneider Individual Corporate OfficerChief Human Resources Officer Aug 1, 2021
Martin Bonick Individual Corporate OfficerCeo-Chain Office Aug 19, 2020
Terika Richardson Mbanu Individual Corporate OfficerCoo Sep 1, 2021
James Grimes Individual Corporate OfficerSVP Assistant Treasurer Sep 1, 2021
Mary a Crabtree Individual Corporate Officer Mar 1, 2018
Alfred Lumsdaine Individual Corporate OfficerCfo Sep 1, 2021
Ahs Management Company Inc. Organization, Brentwood, TN Corporation Operational/Managerial Control Mar 1, 2018 100%
Stephen C Petrovich Individual Corporate Officer Mar 1, 2018
Ardent Legacy Holdings LLC Organization, Brentwood, TN LLC 5% Or Greater Indirect Ownership Interest Mar 1, 2018 100%
Ahs East Texas Health System, LLC Organization, Brentwood, TN LLC 5% Or Greater Direct Ownership Interest Mar 1, 2018 100%
Donald Baker Individual Corporate OfficerCfo Nov 1, 2020 100%
W-2 Managing EmployeeCeo Nov 1, 2020 100%
Ahp Health Partners, Inc Organization, Brentwood, TN Corporation 5% Or Greater Indirect Ownership Interest Mar 1, 2018 100%

Facilities with the same owner 61

Facilities that share an organizational owner with 5% or greater ownership or operational control.

  • Athens Hospital, LLC
    • General Acute Care Hospital
    • Athens, TX
    • NPI 1417465824

    Ahp Health Partners, Inc, Ahs East Texas Health System, LLC, Ahs Management Company Inc., Ahs Texas, LLC, Ardent Health Inc, Ardent Legacy Holdings LLC

    CMS ownership
  • Bsa Hospital LLC
    • General Acute Care Hospital
    • Amarillo, TX
    • NPI 1407191984

    Ahp Health Partners, Inc, Ahs Management Company Inc., Ardent Health Inc, Ardent Legacy Holdings LLC

    CMS ownership
  • Bsa Hospital LLC
    • Rehabilitation Hospital Unit
    • Amarillo, TX
    • NPI 1730425190

    Ahp Health Partners, Inc, Ahs Management Company Inc., Ardent Health Inc, Ardent Legacy Holdings LLC

    CMS ownership
  • Carthage Hospital, LLC
    • Rural Health Clinic/Center
    • Carthage, TX
    • NPI 1407355860

    Ahp Health Partners, Inc, Ahs East Texas Health System, LLC, Ahs Management Company Inc., Ahs Texas, LLC, Ardent Health Inc, Ardent Legacy Holdings LLC

    CMS ownership
  • Carthage Hospital, LLC
    • General Acute Care Hospital
    • Carthage, TX
    • NPI 1538667035

    Ahp Health Partners, Inc, Ahs East Texas Health System, LLC, Ahs Management Company Inc., Ahs Texas, LLC, Ardent Health Inc, Ardent Legacy Holdings LLC

    CMS ownership
  • Carthage Hospital, LLC
    • Rural Health Clinic/Center
    • Carthage, TX
    • NPI 1639678030

    Ahp Health Partners, Inc, Ahs East Texas Health System, LLC, Ahs Management Company Inc., Ahs Texas, LLC, Ardent Health Inc, Ardent Legacy Holdings LLC

    CMS ownership
  • Encompass Health Rehabilitation Hospital of Amarillo, LLC

    dba Rehabilitation Hospital of Amarillo

    • Rehabilitation Hospital
    • Amarillo, TX
    • NPI 1487443099

    Ahp Health Partners, Inc, Ardent Health Inc, Ardent Legacy Holdings LLC

    CMS ownership
  • Etmc Physician Group Inc.
    • Rural Health Clinic/Center
    • Chandler, TX
    • NPI 1235706581

    Ahp Health Partners, Inc, Ahs East Texas Health System, LLC, Ahs Management Company Inc., Ahs Texas, LLC, Ardent Health Inc, Ardent Legacy Holdings LLC

    CMS ownership
  • Etmc Physician Group Inc.
    • Rural Health Clinic/Center
    • Gun Barrel City, TX
    • NPI 1689241945

    Ahp Health Partners, Inc, Ahs East Texas Health System, LLC, Ahs Management Company Inc., Ahs Texas, LLC, Ardent Health Inc, Ardent Legacy Holdings LLC

    CMS ownership
  • FMC - Lubbock LLC

    dba BSA Hospice of the Southwest

    • Community Based Hospice Care Agency
    • Amarillo, TX
    • NPI 1467447854

    Ardent Legacy Holdings LLC

    CMS ownership
  • Henderson Hospital, LLC

    dba UTHealth East Texas Henderson Hospital

    • General Acute Care Hospital
    • Henderson, TX
    • NPI 1326546797

    Ahp Health Partners, Inc, Ahs East Texas Health System, LLC, Ahs Management Company Inc., Ahs Texas, LLC, Ardent Health Inc, Ardent Legacy Holdings LLC

    CMS ownership
  • Henderson Hospital, LLC
    • Rural Health Clinic/Center
    • Henderson, TX
    • NPI 1952800310

    Ahp Health Partners, Inc, Ahs East Texas Health System, LLC, Ahs Management Company Inc., Ahs Texas, LLC, Ardent Health Inc, Ardent Legacy Holdings LLC

    CMS ownership
View all 61

Practitioners & affiliated clinicians

Practitioners 20

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 20

NPI Registry JSON

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

{
    "created_epoch": "1518393600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1696118400000",
    "number": "1861991226",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "340 SEVEN SPRINGS WAY STE 100",
            "city": "BRENTWOOD",
            "state": "TN",
            "postal_code": "370275697",
            "telephone_number": "615-296-3000",
            "fax_number": "615-296-6227"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "203 NACOGDOCHES ST STE 280",
            "city": "JACKSONVILLE",
            "state": "TX",
            "postal_code": "757662444",
            "telephone_number": "903-541-5396",
            "fax_number": "903-591-5393"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JACKSONVILLE HOSPITAL LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "AHS EAST TEXAS HEALTH SYSTEM, LLC",
        "enumeration_date": "2018-02-12",
        "last_updated": "2023-10-01",
        "certification_date": "2023-10-01",
        "status": "A",
        "authorized_official_last_name": "PETROVICH",
        "authorized_official_first_name": "STEPHEN",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "EVP",
        "authorized_official_telephone_number": "615-296-3000"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Jacksonville, TX

Sources for this page

Verify at the official NPI Registry.