Individual
DR. MICHAEL S JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
506 RIVERSIDE PKWY NE, STE 200, ROME, GA 30161-2902
(706) 266-2383
Mailing address
PO BOX 40, SILVER CREEK, GA 30173-0040
(706) 266-9090
(706) 204-8797
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
055376
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000807474B
—
GA
05
—
000807474C
—
GA
05
—
000807474D
—
GA
01
—
1164745782
MEDICARE TYPE 2 ORGANIZATIONAL NPI
—
01
—
1306830062
MEDICARE NPI
—
01
—
202I080352
MEDICARE PTAN
—
Enumeration date
09/08/2005
Last updated
08/12/2019
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