Healthcare Provider Details

I. General information

NPI: 1992036032
Provider Name (Legal Business Name): NORTHEAST ARKANSAS CLINIC CHARITABLE FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2010
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 E JOHNSON AVE
JONESBORO AR
72401-8413
US

IV. Provider business mailing address

350 N HUMPHREYS BLVD
MEMPHIS TN
38120-2177
US

V. Phone/Fax

Practice location:
  • Phone: 501-227-0700
  • Fax: 501-227-0744
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GREGORY M DUCKETT
Title or Position: SR VP/ CLO
Credential:
Phone: 901-227-5233