Provider Demographics
NPI:1043232812
Name:ST BERNARDS HOSPITAL INC
Entity Type:Organization
Organization Name:ST BERNARDS HOSPITAL INC
Other - Org Name:ST BERNARDS DIALYSIS WYNNE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARYLSKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-972-4565
Mailing Address - Street 1:PO BOX 1713
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1713
Mailing Address - Country:US
Mailing Address - Phone:870-972-4172
Mailing Address - Fax:870-933-9666
Practice Address - Street 1:310 FALLS BLVD S
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-3013
Practice Address - Country:US
Practice Address - Phone:870-238-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR4053261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101693105Medicaid