Provider Demographics
NPI:1871738161
Name:MENA SURGICAL CLINIC
Entity type:Organization
Organization Name:MENA SURGICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:QUEBEDEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-394-6100
Mailing Address - Street 1:PO BOX 1325
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-1325
Mailing Address - Country:US
Mailing Address - Phone:479-243-2103
Mailing Address - Fax:479-243-2468
Practice Address - Street 1:400 CRESTWOOD CIR STE L
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-5512
Practice Address - Country:US
Practice Address - Phone:479-243-2103
Practice Address - Fax:479-243-2468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-16
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0207208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5G191Medicare PIN