Healthcare Provider Details

I. General information

NPI: 1417943697
Provider Name (Legal Business Name): JEROLD BENJAMIN CAMPBELL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 MORROW ST N
MENA AR
71953-2516
US

IV. Provider business mailing address

PO BOX 20343
HOT SPRINGS AR
71903-0343
US

V. Phone/Fax

Practice location:
  • Phone: 479-394-6100
  • Fax:
Mailing address:
  • Phone: 501-520-5204
  • Fax: 501-520-5185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC00491
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: