Healthcare Provider Details

I. General information

NPI: 1982940433
Provider Name (Legal Business Name): JEFFERSON HOSPITAL ASSN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2013
Last Update Date: 03/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 W 40TH AVE SUITE 403
PINE BLUFF AR
71603-6319
US

IV. Provider business mailing address

PO BOX 2320
PINE BLUFF AR
71613-2320
US

V. Phone/Fax

Practice location:
  • Phone: 870-541-0668
  • Fax: 870-541-0083
Mailing address:
  • Phone: 870-541-5981
  • Fax: 870-541-8730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberC6122
License Number StateAR

VIII. Authorized Official

Name: WALTER E. JOHNSON
Title or Position: CEO
Credential:
Phone: 870-541-7269