Provider Demographics
NPI:1790867257
Name:MAYFLOWER FAMILY MEDICINE
Entity Type:Organization
Organization Name:MAYFLOWER FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-470-7413
Mailing Address - Street 1:PO BOX 925
Mailing Address - Street 2:
Mailing Address - City:MAYFLOWER
Mailing Address - State:AR
Mailing Address - Zip Code:72106-0925
Mailing Address - Country:US
Mailing Address - Phone:501-470-7413
Mailing Address - Fax:501-470-7415
Practice Address - Street 1:587 HIGHWAY 365
Practice Address - Street 2:
Practice Address - City:MAYFLOWER
Practice Address - State:AR
Practice Address - Zip Code:72106
Practice Address - Country:US
Practice Address - Phone:501-470-7413
Practice Address - Fax:501-470-7415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5B634Medicare ID - Type UnspecifiedMEDICARE GROUP #