{
"Npi": {
"NPI": "1417721689",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "NORTHEAST ARKANSAS CLINIC CHARITABLE FOUNDATION, INC.",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "350 N HUMPHREYS BLVD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MEMPHIS",
"MailingAddressStateName": "TN",
"MailingAddressPostalCode": "38120-2177",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "901-227-5233",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "4800 E JOHNSON AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "JONESBORO",
"PracticeLocationAddressStateName": "AR",
"PracticeLocationAddressPostalCode": "72405-8413",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "870-936-8000",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "11/08/2023",
"LastUpdateDate": "11/08/2023",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "DUCKETT",
"AuthorizedOfficialFirstName": "GREGORY",
"AuthorizedOfficialMiddleName": "M",
"AuthorizedOfficialTitle": "SR VP/CHIEF LEGAL OFFICER",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "SR. VP/CLO",
"AuthorizedOfficialTelephoneNumber": "901-227-5233",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "261QH0100X",
"TaxonomyName": "Health Service Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QM1300X",
"TaxonomyName": "Multi-Specialty Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QP2300X",
"TaxonomyName": "Primary Care Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363AM0700X",
"TaxonomyName": "Medical Physician Assistant",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QR0207X",
"TaxonomyName": "Mobile Mammography Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}