Provider Demographics
NPI:1861790974
Name:JACKSON FLANIGAN MD LLC
Entity type:Organization
Organization Name:JACKSON FLANIGAN MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:
Authorized Official - Last Name:FLANIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-435-2896
Mailing Address - Street 1:1432 CLARK ST STE B
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-9611
Mailing Address - Country:US
Mailing Address - Phone:740-435-2896
Mailing Address - Fax:
Practice Address - Street 1:1432 CLARK ST STE B
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-9611
Practice Address - Country:US
Practice Address - Phone:740-435-2896
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-14
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35061527174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0824620Medicaid
OHE86022Medicare UPIN
OHFL0691161Medicare PIN