Provider Demographics
NPI:1982940433
Name:JEFFERSON HOSPITAL ASSN, INC.
Entity Type:Organization
Organization Name:JEFFERSON HOSPITAL ASSN, INC.
Other - Org Name:SOUTH ARKANSAS CARDIOVASCULAR SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-541-7269
Mailing Address - Street 1:PO BOX 2320
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71613-2320
Mailing Address - Country:US
Mailing Address - Phone:870-541-5981
Mailing Address - Fax:870-541-8730
Practice Address - Street 1:1609 W 40TH AVE
Practice Address - Street 2:SUITE 403
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6319
Practice Address - Country:US
Practice Address - Phone:870-541-0668
Practice Address - Fax:870-541-0083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-02
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC6122208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty