Healthcare Provider Details

I. General information

NPI: 1023005550
Provider Name (Legal Business Name): JEFFERSON ANESTHESIOLOGY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 04/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W 40TH AVE SUITE 2B
PINE BLUFF AR
71603-6900
US

IV. Provider business mailing address

PO BOX 1272
PINE BLUFF AR
71613-1272
US

V. Phone/Fax

Practice location:
  • Phone: 870-535-7457
  • Fax:
Mailing address:
  • Phone: 870-535-7457
  • Fax: 870-535-2522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: FERDINAND K SAMUEL
Title or Position: ADMINISTRATOR/PARTNER
Credential: M.D.
Phone: 870-535-7457