1043493992 NPI number — COMMUNITY PHYSICIANS GROUP

Table of content: (NPI 1043493992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043493992 NPI number — COMMUNITY PHYSICIANS GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY PHYSICIANS GROUP
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:
1043493992
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1374
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SILOAM SPRINGS
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72761-1374
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-549-3079
Provider Business Mailing Address Fax Number:
479-549-3275

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
419 S WILLIAMS
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTVILLE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-723-5456
Provider Business Practice Location Address Fax Number:
918-723-4080
Provider Enumeration Date:
12/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHAMBERS
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
E
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
479-549-3079

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: CI2712 . This is a "RR MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 135299002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5C090 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 100747540A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: CI2710 . This is a "RR MEDICARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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