Provider Demographics
NPI:1083035232
Name:JACKSON COUNTY HOSPITAL DISTRICT
Entity type:Organization
Organization Name:JACKSON COUNTY HOSPITAL DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-718-2623
Mailing Address - Street 1:4250 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-1917
Mailing Address - Country:US
Mailing Address - Phone:850-526-2200
Mailing Address - Fax:850-718-2844
Practice Address - Street 1:4318 5TH AVE
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2182
Practice Address - Country:US
Practice Address - Phone:850-526-5300
Practice Address - Fax:850-428-5021
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSON COUNTY HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-13
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL660233900Medicaid
FLW42OtherBCBS
FL660233900Medicaid