Provider Demographics
NPI:1275541427
Name:PINE BLUFF ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:PINE BLUFF ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:O.T.
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:870-534-3344
Mailing Address - Street 1:1609 W 40TH AVE
Mailing Address - Street 2:SUITE 312
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6319
Mailing Address - Country:US
Mailing Address - Phone:870-534-2626
Mailing Address - Fax:870-534-3517
Practice Address - Street 1:1609 W 40TH AVE
Practice Address - Street 2:SUITE 312
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6319
Practice Address - Country:US
Practice Address - Phone:870-534-2626
Practice Address - Fax:870-534-3517
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GASTROENTEROLOGY ASSOCIATES OF SOUTHEAST ARKANSAS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-04
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR4347261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161691128Medicaid
ARP00355592OtherRAIL ROAD MEDICARE
AR11066OtherBLUE CROSS BLUE SHIELD
ARP00355592OtherRAIL ROAD MEDICARE