1003149493 NPI number — RICHARD K DAVIS MD PLLC PA

Table of content: (NPI 1003149493)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003149493 NPI number — RICHARD K DAVIS MD PLLC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RICHARD K DAVIS MD PLLC 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:
1003149493
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 69
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SMACKOVER
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71762-0069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-725-3471
Provider Business Mailing Address Fax Number:
870-725-3215

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 PERSHING HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMACKOVER
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71762-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-725-3471
Provider Business Practice Location Address Fax Number:
870-725-3215
Provider Enumeration Date:
09/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
K
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
870-725-3471

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  C6398 , 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: 51303 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 106187001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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