Basic Information
| Provider Information | |||||||||
| NPI: | 1922043686 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST BERNARDS HOSPITAL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ST BERNARDS MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 E WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724013111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709724100 | ||||||||
| FaxNumber: | 8709745112 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 E WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724013111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709724100 | ||||||||
| FaxNumber: | 8709745112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARBER | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8709724429 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST BERNARDS HEALTH CARE | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | AR4053 | AR | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 268358 | 01 | AR | BLACK LUNG | OTHER | BLUE CROSS OF MO | 01 | MO | 10AR307 | OTHER | 10020 | 01 | AR | BLUE CROSS | OTHER | 101693105 | 05 | AR | MEDICAID | 010327302 | 05 | MO | MEDICAID | 29280 | 01 | WA | WASHINGTON IND. ST. FUND | OTHER |