1174504641 NPI number — PATRICIA LYNN ELETHORP DO

Table of content: PATRICIA LYNN ELETHORP DO (NPI 1174504641)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174504641 NPI number — PATRICIA LYNN ELETHORP DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELETHORP
Provider First Name:
PATRICIA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ELETHORP GARNER
Provider Other First Name:
PATRICIA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174504641
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1196
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMPTON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71744-1196
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-798-4064
Provider Business Mailing Address Fax Number:
870-798-4100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
253 SOUTH CONCORD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STRONG
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71765-0565
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-797-7620
Provider Business Practice Location Address Fax Number:
870-798-4100
Provider Enumeration Date:
11/10/2005

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: 207Q00000X , with the licence number:  E6834 , 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: 204510003 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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