Provider Demographics
NPI:1710934542
Name:JEFFERSON SURGERY CENTER PLLC
Entity Type:Organization
Organization Name:JEFFERSON SURGERY CENTER PLLC
Other - Org Name:JHA AMBULATORY SURGERY CENTER, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOHANNAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:870-541-3640
Mailing Address - Street 1:1609 W 40TH AVE
Mailing Address - Street 2:JRMC PROFESSIONAL CENTER, SUITE 103
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6329
Mailing Address - Country:US
Mailing Address - Phone:870-541-3636
Mailing Address - Fax:870-541-3639
Practice Address - Street 1:1609 W 40TH AVE
Practice Address - Street 2:JRMC PROFESSIONAL CENTER, SUITE 103
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6329
Practice Address - Country:US
Practice Address - Phone:870-541-3636
Practice Address - Fax:870-541-3639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR3637261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR135346128Medicaid
AR135346128Medicaid