1013161363 NPI number — PRIMARY CARE OF ARKANSAS CHRYSTAL JOHNSON MD

Table of content: (NPI 1013161363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013161363 NPI number — PRIMARY CARE OF ARKANSAS CHRYSTAL JOHNSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIMARY CARE OF ARKANSAS CHRYSTAL JOHNSON MD
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:
1013161363
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 S UNIVERSITY AVE
Provider Second Line Business Mailing Address:
SUITE 515
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72205-5302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-666-6100
Provider Business Mailing Address Fax Number:
501-666-6107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 S UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
SUITE 515
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72205-5302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-666-6100
Provider Business Practice Location Address Fax Number:
501-666-6107
Provider Enumeration Date:
11/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
CHRYSTAL
Authorized Official Middle Name:
DIAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
501-666-6100

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 150345001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 181136002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04010017400 . This is a "QUAL CHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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