1558641548 NPI number — JONESBORO SURGERY CENTER ANESTHESIA PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558641548 NPI number — JONESBORO SURGERY CENTER ANESTHESIA PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JONESBORO SURGERY CENTER ANESTHESIA PLLC
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:
1558641548
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
623 E MATTHEWS AVE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72401-3145
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-934-8010
Provider Business Mailing Address Fax Number:
870-934-8020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
623 E MATTHEWS AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72401-3145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-934-8010
Provider Business Practice Location Address Fax Number:
870-934-8020
Provider Enumeration Date:
08/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BACOT
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRRATOR
Authorized Official Telephone Number:
870-934-8010

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com