Individual
SAMUEL PORTER JACKS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
4622 COUNTRY CLUB RD, SUITE 180, WINSTON SALEM, NC 27104-3769
(336) 768-9535
(336) 768-4155
Mailing address
PO BOX 60447, CHARLOTTE, NC 28260-0447
(336) 768-9535
(336) 768-4155
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
2015-01953
NC
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
Primary
2015-01953
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003125978A
—
GA
05
—
005979900
—
FL
01
—
P01084809
RAILROAD MEDICARE
FL
Enumeration date
06/13/2007
Last updated
10/25/2020
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