1619071305 NPI number — USRC OF SE ARKANSAS LLC

Table of content: (NPI 1619071305)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619071305 NPI number — USRC OF SE ARKANSAS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
USRC OF SE ARKANSAS LLC
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:
STUTTGART - US RENAL CARE
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:
1619071305
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 19119
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72403-6601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-931-5400
Provider Business Mailing Address Fax Number:
870-931-5418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
805 W. MADISON STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STUTTGART
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72160-2543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-673-0008
Provider Business Practice Location Address Fax Number:
870-673-0091
Provider Enumeration Date:
09/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEINBERG
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
L
Authorized Official Title or Position:
VICE PRESIDENT GENERAL COUNSEL
Authorized Official Telephone Number:
972-736-2700

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , 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: 162017134 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12579 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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