Basic Information
| Provider Information | |||||||||
| NPI: | 1043413909 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IRWIN | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEARNE | ||||||||
| OtherFirstName: | JAMIE | ||||||||
| OtherMiddleName: | CHARLENE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 21850 | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719031850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017679111 | ||||||||
| FaxNumber: | 5017673433 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 MCAULEY CT | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719136314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013212546 | ||||||||
| FaxNumber: | 5013211838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2007 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | E5512 | AR | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 168836003 | 05 | AR | MEDICAID |