1346534047 NPI number — ARKANSAS FOOT & ANKLE CLINIC, PA

Table of content: (NPI 1346534047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346534047 NPI number — ARKANSAS FOOT & ANKLE CLINIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARKANSAS FOOT & ANKLE CLINIC, PA
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:
Provider Other Organization Name Type Code:
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:
1346534047
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1801 W 40TH AVE
Provider Second Line Business Mailing Address:
SUITE 4E
Provider Business Mailing Address City Name:
PINE BLUFF
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71603-6940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-535-4850
Provider Business Mailing Address Fax Number:
870-535-3558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 W 40TH AVE
Provider Second Line Business Practice Location Address:
SUITE 4E
Provider Business Practice Location Address City Name:
PINE BLUFF
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71603-6940
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-535-4850
Provider Business Practice Location Address Fax Number:
870-535-3558
Provider Enumeration Date:
05/31/2011

Additional Information

Authorized Official

Authorized Official Last Name:
THRASH
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
PODIATRIST
Authorized Official Telephone Number:
870-535-4850

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  162 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 17389000000 . This is a "QUAL CHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 2720022 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 480021446 . This is a "PALMETTO" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 5T328 . This is a "BLUE CROSS AND BLUE SHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 4249008 . This is a "AETNA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 130021717 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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