1477529436 NPI number — RUSSELLVILLE DERMATOLOGY CLINIC PA

Table of content: (NPI 1477529436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477529436 NPI number — RUSSELLVILLE DERMATOLOGY CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RUSSELLVILLE DERMATOLOGY 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:
1477529436
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 843
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSSELLVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72811-0843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-968-6969
Provider Business Mailing Address Fax Number:
479-968-4290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1602 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUSSELLVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72801-2720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-968-6969
Provider Business Practice Location Address Fax Number:
479-968-4290
Provider Enumeration Date:
02/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GALLOWAY
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT / OWNER
Authorized Official Telephone Number:
479-968-6969

Provider Taxonomy Codes

  • Taxonomy code: 207NS0135X , with the licence number:  MC0841 , 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: 110005002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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