1669561411 NPI number — LINDSAY R MELSON APN

Table of content: LINDSAY R MELSON APN (NPI 1669561411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669561411 NPI number — LINDSAY R MELSON APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MELSON
Provider First Name:
LINDSAY
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

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:
1669561411
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11001 EXECUTIVE CENTER DRIVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72211-7101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-812-7587
Provider Business Mailing Address Fax Number:
501-812-7588

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9500 KANIS RD
Provider Second Line Business Practice Location Address:
HICKINGBOTHAM OUTPAITENT CENTER
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72205-6324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-202-1902
Provider Business Practice Location Address Fax Number:
501-202-1512
Provider Enumeration Date:
10/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  A02926 , 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: 71-0781138 . This is a "GREAT WEST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 710781138028 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4345098 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5A116 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".