Healthcare Provider Details

I. General information

NPI: 1235179581
Provider Name (Legal Business Name): JEFFERSON HOSPITAL ASSOCIATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W 40TH AVE ATTN: HOSPITALIST PROGRAM
PINE BLUFF AR
71603-6301
US

IV. Provider business mailing address

1600 W 40TH AVE ATTN: HOSPITALIST PROGRAM
PINE BLUFF AR
71603-6301
US

V. Phone/Fax

Practice location:
  • Phone: 870-850-6053
  • Fax: 870-850-6482
Mailing address:
  • Phone: 870-850-6053
  • Fax: 870-850-6482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: TANYA M SIMPSON
Title or Position: PRESIDENT
Credential:
Phone: 870-850-6053