Basic Information
| Provider Information | |||||||||
| NPI: | 1033404199 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACK STEPHENS HEART INSTITUTE LLC | ||||||||
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| OtherOrganizationName: | ST. VINCENT CARDIOVASCULAR SURGEONS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 ST. VINCENT CIRCLE | ||||||||
| Address2: | STE 501 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722055414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016662894 | ||||||||
| FaxNumber: | 5016669017 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 ST. VINCENT CIRCLE | ||||||||
| Address2: | STE 501 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722055414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016662894 | ||||||||
| FaxNumber: | 5016669017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2011 | ||||||||
| LastUpdateDate: | 02/09/2012 | ||||||||
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| AuthorizedOfficialLastName: | BANKO | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5015523922 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.