Provider Demographics
NPI:1457379364
Name:JONESBORO SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:JONESBORO SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
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:
Mailing Address - Fax:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR3943261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
490005365OtherRAILROAD MEDICARE
AR11048OtherAR BLUE CROSS BLUE SHIELD
AR143775128Medicaid
AR143775128Medicaid
AR11048Medicare PIN
490005365OtherRAILROAD MEDICARE