1124466701 NPI number — PHOMAKAY PRIMARY CARE PA

Table of content: (NPI 1124466701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124466701 NPI number — PHOMAKAY PRIMARY CARE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOMAKAY PRIMARY CARE 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:
1124466701
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10154
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72917-0154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-782-5500
Provider Business Mailing Address Fax Number:
479-782-5502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10301 MAYO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARLING
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72923-1660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-782-5500
Provider Business Practice Location Address Fax Number:
479-782-5502
Provider Enumeration Date:
06/05/2013

Additional Information

Authorized Official

Authorized Official Last Name:
PHOMAKAY
Authorized Official First Name:
CHANSAMONE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
479-782-5500

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  E-6214 , 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)





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