1376848978 NPI number — FAMILY MEDICAL WALK-IN CLINIC PA

Table of content: (NPI 1376848978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376848978 NPI number — FAMILY MEDICAL WALK-IN CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY MEDICAL WALK-IN 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:
ROGERS FAMILY MEDICAL WALK-IN CLINIC
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:
1376848978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4049 S CAMPBELL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65807-5303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-890-5550
Provider Business Mailing Address Fax Number:
417-889-6898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1310 W WALNUT ST
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
ROGERS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72756-3316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-707-5550
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BURKE
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER/MEDICAL DIRECTOR
Authorized Official Telephone Number:
417-890-5550

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 186131002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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