Basic Information
| Provider Information | |||||||||
| NPI: | 1710931134 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NOVAMED SURGERY CENTER OF JONESBORO, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EYE SURGERY CENTER OF ARKANSAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 E MATTHEWS AVE | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724013145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709356396 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 601 E MATTHEWS AVE | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724013145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709356396 | ||||||||
| FaxNumber: | 8709354063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MACOMBER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 3127803234 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NOVAMED, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 2436 | AR | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 502611601 | 05 | MO | MEDICAID | 163018128 | 05 | AR | MEDICAID |