Provider Demographics
NPI:1417943697
Name:CAMPBELL, JEROLD BENJAMIN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JEROLD
Middle Name:BENJAMIN
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20343
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71903-0343
Mailing Address - Country:US
Mailing Address - Phone:501-520-5204
Mailing Address - Fax:501-520-5185
Practice Address - Street 1:311 MORROW ST N
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-2516
Practice Address - Country:US
Practice Address - Phone:479-394-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC00491367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR113755001Medicaid
430080341OtherRR MEDICARE GROUP CK6327
AR59312OtherAR BCBS
AR59312Medicare PIN
AR59312C752Medicare PIN
430080341OtherRR MEDICARE GROUP CK6327
AR59312OtherAR BCBS
AR5V488C752Medicare PIN