Provider Demographics
NPI:1558641548
Name:JONESBORO SURGERY CENTER ANESTHESIA PLLC
Entity Type:Organization
Organization Name:JONESBORO SURGERY CENTER ANESTHESIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BACOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-934-8010
Mailing Address - Street 1:623 E MATTHEWS AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3145
Mailing Address - Country:US
Mailing Address - Phone:870-934-8010
Mailing Address - Fax:870-934-8020
Practice Address - Street 1:623 E MATTHEWS AVE
Practice Address - Street 2:SUITE C
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3145
Practice Address - Country:US
Practice Address - Phone:870-934-8010
Practice Address - Fax:870-934-8020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-22
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR11048Medicare PIN
AR143775128Medicaid