Basic Information
| Provider Information | |||||||||
| NPI: | 1376844878 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSISSIPPI COUNTY HOSPITAL SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 167 | ||||||||
| Address2: | |||||||||
| City: | BLYTHEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723160167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708387445 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1520 N DIVISION ST | ||||||||
| Address2: | ANESTHESIA DEPARTMENT | ||||||||
| City: | BLYTHEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723151448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708387300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2010 | ||||||||
| LastUpdateDate: | 04/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | MCGUIRE | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | COUNTY JUDGE | ||||||||
| AuthorizedOfficialTelephone: | 8708387463 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 999999 | AR | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0000X | 999999 | AR | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0014X | 999999 | AR | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 367500000X | 999999 | AR | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | 999999 | AR | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 185918002 | 05 | AR | MEDICAID | 185919002 | 05 | AR | MEDICAID | 5B014 | 01 | AR | BLUECROSS BLUESHIELD OF ARKANSAS | OTHER |