Provider Demographics
NPI:1215347414
Name:ER PHYSICIANS GROUP AT JACKSON HOSPITAL
Entity type:Organization
Organization Name:ER PHYSICIANS GROUP AT JACKSON HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHYSICIAN PRACTICES
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:MONIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-718-2677
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:850-718-2677
Mailing Address - Fax:
Practice Address - Street 1:436 3RD AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446
Practice Address - Country:US
Practice Address - Phone:850-718-2677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019459208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty