Provider Demographics
NPI:1437261617
Name:R. ELLIOTT JACKSON GERIATRICS,LLC
Entity type:Organization
Organization Name:R. ELLIOTT JACKSON GERIATRICS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAMSEY
Authorized Official - Middle Name:ELLIOTT
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-213-3672
Mailing Address - Street 1:3904 N DRUID HILLS RD
Mailing Address - Street 2:#222
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-3105
Mailing Address - Country:US
Mailing Address - Phone:770-458-1594
Mailing Address - Fax:770-458-1596
Practice Address - Street 1:2650 WEIGELIA RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3969
Practice Address - Country:US
Practice Address - Phone:404-213-3672
Practice Address - Fax:770-458-1596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047774207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP5097Medicare ID - Type Unspecified