Healthcare Provider Details

I. General information

NPI: 1710934542
Provider Name (Legal Business Name): JEFFERSON SURGERY CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 W 40TH AVE JRMC PROFESSIONAL CENTER, SUITE 103
PINE BLUFF AR
71603-6329
US

IV. Provider business mailing address

1609 W 40TH AVE JRMC PROFESSIONAL CENTER, SUITE 103
PINE BLUFF AR
71603-6329
US

V. Phone/Fax

Practice location:
  • Phone: 870-541-3636
  • Fax: 870-541-3639
Mailing address:
  • Phone: 870-541-3636
  • Fax: 870-541-3639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberAR3637
License Number StateAR

VIII. Authorized Official

Name: MRS. CRYSTAL R BOHANNAN
Title or Position: ADMINISTRATOR
Credential: CPA
Phone: 870-541-3640