Provider Demographics
NPI:1851421861
Name:JEFFERSON REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:JEFFERSON REGIONAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-541-7214
Mailing Address - Street 1:1600 W 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6301
Mailing Address - Country:US
Mailing Address - Phone:870-541-7100
Mailing Address - Fax:870-541-7499
Practice Address - Street 1:1600 W 40TH AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6301
Practice Address - Country:US
Practice Address - Phone:870-541-7100
Practice Address - Fax:870-541-7499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR056663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100339407Medicaid
ARAJ3219664OtherIP PHARM DEA NUMBER
ARAJ6766630OtherOP PHARM DEA NUMBER