Individual Professional Information |
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NPI
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1649217191
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Unique healthcare provider (clinician) ID assigned by NPPES
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PECOS UID
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2365582624
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Unique individual clinician ID assigned by PECOS
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Professional Enrollment ID
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I20091216000595
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Unique ID for the individual professional enrollment that is the source for the data in the observation
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Provider Last Name
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AGENT
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Individual professional last name
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Provider First Name
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JOHN
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Individual professional first name
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Provider Middle Name
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P
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Individual professional middle name
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Provider Gender
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M
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The provider's gender if the provider is a person.
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Practice Information |
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Organization Legal Name
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BAPTIST HEALTH SERVICES
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Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
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Group Practice PAC ID
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0648514133
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Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
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Number of Group Practice members
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113
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Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
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Line 1 Street Address
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1001 TOWSON AVE
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Group Practice or individual's line 1 address
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Marker of address line 2 suppression
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Y
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Marker that address as reported may be incomplete
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City
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FORT SMITH
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Group Practice or individual's city
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State
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AR
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Group Practice or individual's state
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Zip Code
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729014921
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Group Practice or individual's zip code (9 digits when available)
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Hospital(s) Affiliation Information |
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Hospital Affiliation CCN 1
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040062
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Medicare CCN of hospital where individual professional provides service 1
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Hospital Affiliation LBN 1
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MERCY HOSPITAL FORT SMITH
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Legal business name of hospital where individual professional provides service 1
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Hospital Affiliation CCN 2
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370112
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Medicare CCN of hospital where individual professional provides service 2
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Hospital Affiliation LBN 2
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SEQUOYAH COUNTY-CITY OF SALLISAW HOSPITAL AUTHORIT
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Legal business name of hospital where individual professional provides service 2
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Hospital Affiliation CCN 3
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040055
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Medicare CCN of hospital where individual professional provides service 3
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Hospital Affiliation LBN 3
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SPARKS REGIONAL MEDICAL CENTER
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Legal business name of hospital where individual professional provides service 3
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Hospital Affiliation CCN 4
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371337
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Medicare CCN of hospital where individual professional provides service 4
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Hospital Affiliation LBN 4
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EASTERN OKLAHOMA MEDICAL CENTER
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Legal business name of hospital where individual professional provides service 4
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Hospital Affiliation CCN 5
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370089
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Medicare CCN of hospital where individual professional provides service 5
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Hospital Affiliation LBN 5
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NORTHEASTERN HEALTH SYSTEM
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Legal business name of hospital where individual professional provides service 5
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Professional Accepts Medicare Assignment
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Y
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