1689898140 NPI number — ST BERNARDS COMMUNITY HOSPITAL CORP

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 1689898140 NPI number — ST BERNARDS COMMUNITY HOSPITAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST BERNARDS COMMUNITY HOSPITAL CORP
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:
6
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:
1689898140
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 FALLS BLVD S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WYNNE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72396-3013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-238-3300
Provider Business Mailing Address Fax Number:
870-238-7432

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 FALLS BLVD S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WYNNE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72396-3013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-238-3300
Provider Business Practice Location Address Fax Number:
870-238-7432
Provider Enumeration Date:
04/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MATTES
Authorized Official First Name:
BRYAN
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSOCIATE ADMINISTRATOR
Authorized Official Telephone Number:
870-238-3300

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X , with the licence number:  AR4063 , 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: 57861 . This is a "BLUE CROSS CRNA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 120461702 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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