Provider Demographics
NPI:1497102040
Name:JEFFERSON HOSPITAL ASSOCIATION, INC
Entity Type:Organization
Organization Name:JEFFERSON HOSPITAL ASSOCIATION, INC
Other - Org Name:FAMILY HEALTH ASSOCIATES OF SOUTHEAST ARKANSAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP AND COO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-541-7235
Mailing Address - Street 1:PO BOX 2650
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71613-2650
Mailing Address - Country:US
Mailing Address - Phone:870-541-7235
Mailing Address - Fax:870-541-4297
Practice Address - Street 1:4747 DUSTY LAKE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-8742
Practice Address - Country:US
Practice Address - Phone:870-541-7235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty