Provider Demographics
NPI:1144481599
Name:JACKSONVILLE NEUROLOGY, PA
Entity type:Organization
Organization Name:JACKSONVILLE NEUROLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-985-1323
Mailing Address - Street 1:PO BOX 875
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72115-0875
Mailing Address - Country:US
Mailing Address - Phone:501-985-1323
Mailing Address - Fax:501-985-3229
Practice Address - Street 1:4020 RICHARDS RD
Practice Address - Street 2:SUITE C
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-2650
Practice Address - Country:US
Practice Address - Phone:501-985-1323
Practice Address - Fax:501-985-3229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE12012084P2900X, 2084S0012X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Multi-Specialty
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR132333002Medicaid