Provider Demographics
NPI:1821021379
Name:JEFFERSON HOSPITAL ASSOCIATION, INC.
Entity Type:Organization
Organization Name:JEFFERSON HOSPITAL ASSOCIATION, INC.
Other - Org Name:RHUEMATOLOGY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-541-7269
Mailing Address - Street 1:1609 W 40TH AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6319
Mailing Address - Country:US
Mailing Address - Phone:870-534-2348
Mailing Address - Fax:870-850-6816
Practice Address - Street 1:1609 W 40TH AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6319
Practice Address - Country:US
Practice Address - Phone:870-534-2348
Practice Address - Fax:870-850-6816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2787302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F782OtherBLUE CROSS
AR165800002Medicaid
AR165800002Medicaid