Healthcare Provider Details

I. General information

NPI: 1558140822
Provider Name (Legal Business Name): ST BERNARDS PHYSICIAN CLINICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2023
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E OAK AVE
JONESBORO AR
72401-4163
US

IV. Provider business mailing address

PO BOX 1331
JONESBORO AR
72403-1331
US

V. Phone/Fax

Practice location:
  • Phone: 870-935-6729
  • Fax: 870-268-4478
Mailing address:
  • Phone: 870-932-7024
  • Fax: 870-930-9377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN LIEBLONG
Title or Position: PRESIDENT
Credential:
Phone: 870-932-7024