1710931985 NPI number — JEFFERSON HOSPITAL ASSOCIATION INC

Table of content: (NPI 1710931985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710931985 NPI number — JEFFERSON HOSPITAL ASSOCIATION INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFERSON HOSPITAL ASSOCIATION INC
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:
1710931985
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 W. 40TH AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINE BLUFF
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71603-6301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-541-7100
Provider Business Mailing Address Fax Number:
870-541-7966

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 W. 40TH AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINE BLUFF
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71603-6301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-541-7100
Provider Business Practice Location Address Fax Number:
870-541-7964
Provider Enumeration Date:
05/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
KRISTEN
Authorized Official Middle Name:
JADE
Authorized Official Title or Position:
DIRECTOR OF REIMBURSEMENT
Authorized Official Telephone Number:
870-541-7173

Provider Taxonomy Codes

  • Taxonomy code: 273R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 273Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 273Y00000X , with the licence number: AR4213 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X , with the licence number: AR4213 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 040071 . This is a "MEDICARE PART A" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 103078002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5000023 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 045307 . This is a "MEDICARE PART A" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 04S071 . This is a "MEDICARE PART A" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 10071 . This is a "BLUE CROSS PROVIDER #" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 102916105 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 15307 . This is a "BLUE CROSS SNF PROVIDER #" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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