Provider Demographics
NPI:1487081469
Name:JOHNSON REGIONAL MEDICAL CENTER SPECIALTY PHYSICIANS
Entity type:Organization
Organization Name:JOHNSON REGIONAL MEDICAL CENTER SPECIALTY PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:C
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-754-5454
Mailing Address - Street 1:PO BOX 738
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-0738
Mailing Address - Country:US
Mailing Address - Phone:479-754-5454
Mailing Address - Fax:
Practice Address - Street 1:1000 E POPLAR ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-4402
Practice Address - Country:US
Practice Address - Phone:479-754-5454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHNSON REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3265207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty