Provider Demographics
NPI:1649496357
Name:JIMMERSON FAMILY HEALTH CARE P.A.
Entity type:Organization
Organization Name:JIMMERSON FAMILY HEALTH CARE P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:TYRAY
Authorized Official - Last Name:JIMMERSON
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:501-569-9961
Mailing Address - Street 1:6917 GEYER SPRINGS RD
Mailing Address - Street 2:SUITE 4S
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72209-2727
Mailing Address - Country:US
Mailing Address - Phone:501-569-9961
Mailing Address - Fax:501-569-9903
Practice Address - Street 1:6917 GEYER SPRINGS RD
Practice Address - Street 2:SUITE 4S
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-2727
Practice Address - Country:US
Practice Address - Phone:501-569-9961
Practice Address - Fax:501-569-9903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-1845207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR18321000000OtherQUAL CHOICE
AR135241001Medicaid
2451550OtherAETNA
2717169OtherCIGNA
AR5K890OtherBCBS
AR080158974OtherPALMETTOGBA
AR5K890Medicare PIN
AR18321000000OtherQUAL CHOICE