Provider Demographics
NPI:1235201112
Name:CHICOT MEMORIAL HOSPITAL ANESTHESIA
Entity Type:Organization
Organization Name:CHICOT MEMORIAL HOSPITAL ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-265-5351
Mailing Address - Street 1:2729 HWY 65 & 82 SOUTH
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653
Mailing Address - Country:US
Mailing Address - Phone:870-265-5351
Mailing Address - Fax:870-265-3910
Practice Address - Street 1:2729 HWY 65 & 82 SOUTH
Practice Address - Street 2:
Practice Address - City:LAKE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71653
Practice Address - Country:US
Practice Address - Phone:870-265-5351
Practice Address - Fax:870-265-3910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR4314282NC0060X
ARAR3934367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered282NC0060XHospitalsGeneral Acute Care HospitalCritical AccessGroup - Multi-Specialty
Not Answered367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
57919Medicare ID - Type Unspecified