MEDICARE: JIMMERSON FAMILY HEALTH CARE P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	E-1845	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	18321000000	OTHER	AR	QUAL CHOICE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	2451550	OTHER		AETNA
4	2717169	OTHER		CIGNA
5	5K890	OTHER	AR	BCBS
6	080158974	OTHER	AR	PALMETTOGBA

General Provider Information

NPI Number	:	1649496357
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JIMMERSON FAMILY HEALTH CARE P.A.

Provider Business Mailing Address
First Line	:	6917 GEYER SPRINGS RD
Second Line	:	SUITE 4S
City	:	LITTLE ROCK
State	:	AR
Zip	:	72209-2727
Country	:	US
Telephone Number	:	501-569-9961
Fax Number	:	501-569-9903

Provider Business Practice Location Address
First Line	:	6917 GEYER SPRINGS RD
Second Line	:	SUITE 4S
City	:	LITTLE ROCK
State	:	AR
Zip	:	72209-2727
Country	:	US
Telephone Number	:	501-569-9961
Fax Number	:	501-569-9903

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. ROBERT TYRAY JIMMERSON II
Credential	:	M.D.
Telephone Number	:	501-569-9961

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	05/06/2008

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