Organization
ER PHYSICIAN GROUP AT JACKSON HOSPITAL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. KELLY CONNOLLY (CFO)
(850) 718-2623
Entity
Organization
Contact information
Practice address
4250 HOSPITAL DR, MARIANNA, FL 32446-1917
(850) 526-2200
(850) 718-2649
Mailing address
4250 HOSPITAL DR, MARIANNA, FL 32446-1917
(850) 526-2200
(850) 718-2649
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
—
—
208D00000X
General Practice Physician
Primary
—
—
261QR1300X
Rural Health Clinic/Center
—
—
282NR1301X
Rural Acute Care Hospital
3999
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
054877400
—
FL
01
—
38679
BLUE CROSS
FL
01
—
CJ6133
MEDICARE RAIL ROAD
FL
Enumeration date
05/23/2006
Last updated
01/23/2023
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