Provider Demographics
NPI:1275841306
Name:JEFFERSON HOSPITAL ASSOCIATION, INC.
Entity Type:Organization
Organization Name:JEFFERSON HOSPITAL ASSOCIATION, INC.
Other - Org Name:SOUTH ARKANSAS ORTHOPAEDIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-541-7269
Mailing Address - Street 1:1609 W 40TH AVE
Mailing Address - Street 2:SUITE 501
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6319
Mailing Address - Country:US
Mailing Address - Phone:870-534-3449
Mailing Address - Fax:870-535-3973
Practice Address - Street 1:1609 W 40TH AVE
Practice Address - Street 2:SUITE 501
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6319
Practice Address - Country:US
Practice Address - Phone:870-534-3449
Practice Address - Fax:870-535-3973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5G334OtherBCBS
AR185009002Medicaid
AR5G662Medicare PIN