Provider Demographics
NPI:1811255987
Name:CROSSETT HEALTH FOUNDATION
Entity type:Organization
Organization Name:CROSSETT HEALTH FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:GILMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-364-1271
Mailing Address - Street 1:1003 FRED LAGRONE DR
Mailing Address - Street 2:
Mailing Address - City:CROSSETT
Mailing Address - State:AR
Mailing Address - Zip Code:71635-4546
Mailing Address - Country:US
Mailing Address - Phone:870-364-3800
Mailing Address - Fax:870-364-3811
Practice Address - Street 1:1003 FRED LAGRONE DR
Practice Address - Street 2:
Practice Address - City:CROSSETT
Practice Address - State:AR
Practice Address - Zip Code:71635-4546
Practice Address - Country:US
Practice Address - Phone:870-364-3800
Practice Address - Fax:870-364-3811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR282NC0060X282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150522729Medicaid
AR43490Medicare UPIN