1649496357 NPI number — JIMMERSON FAMILY HEALTH CARE P.A.

Table of content: (NPI 1649496357)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649496357 NPI number — JIMMERSON FAMILY HEALTH CARE P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JIMMERSON FAMILY HEALTH CARE P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649496357
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6917 GEYER SPRINGS RD
Provider Second Line Business Practice Location Address:
SUITE 4S
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72209-2727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-569-9961
Provider Business Practice Location Address Fax Number:
501-569-9903
Provider Enumeration Date:
04/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JIMMERSON
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
TYRAY
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
501-569-9961

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  E-1845 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 18321000000 . This is a "QUAL CHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 135241001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2451550 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2717169 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5K890 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 080158974 . This is a "PALMETTOGBA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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