Provider Demographics
NPI:1023005550
Name:JEFFERSON ANESTHESIOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:JEFFERSON ANESTHESIOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:FERDINAND
Authorized Official - Middle Name:K
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-535-7457
Mailing Address - Street 1:PO BOX 1272
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71613-1272
Mailing Address - Country:US
Mailing Address - Phone:870-535-7457
Mailing Address - Fax:870-535-2522
Practice Address - Street 1:1801 W 40TH AVE
Practice Address - Street 2:SUITE 2B
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6900
Practice Address - Country:US
Practice Address - Phone:870-535-7457
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR57360OtherBCBS
CP0148OtherRRMCR/PGBA
AR103014002Medicaid
AR103014002Medicaid
AR57360Medicare ID - Type Unspecified