MEDICARE: ST BERNARDS PHYSICIAN CLINICS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1083307896
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST BERNARDS PHYSICIAN CLINICS INC

Provider Business Mailing Address
First Line	:	PO BOX 1331
Second Line	:
City	:	JONESBORO
State	:	AR
Zip	:	72403-1331
Country	:	US
Telephone Number	:	870-932-7024
Fax Number	:	870-930-9377

Provider Business Practice Location Address
First Line	:	800 S CHURCH ST STE 302
Second Line	:
City	:	JONESBORO
State	:	AR
Zip	:	72401-4107
Country	:	US
Telephone Number	:	870-935-3990
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHN LIEBLONG
Credential	:
Telephone Number	:	870-932-7024

Provider Enumeration Date	:	05/29/2023
Last Update Date	:	05/29/2023

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