1124037866 NPI number — ARKANSAS HEALTH GROUP

Table of content: (NPI 1124037866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124037866 NPI number — ARKANSAS HEALTH GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARKANSAS HEALTH GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BAPTIST HEALTH FAMILY CLINIC MAUMELLE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124037866
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11001 EXECUTIVE CENTER DR STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72211-4393
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-812-7215
Provider Business Mailing Address Fax Number:
501-812-7207

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 CLUB MANOR DR
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
MAUMELLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72113-7400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-851-7400
Provider Business Practice Location Address Fax Number:
501-851-4753
Provider Enumeration Date:
08/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUSHER
Authorized Official First Name:
WILL
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
501-812-7500

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 129802002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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