1245295443 NPI number — DR. JOHN KEITH HEDGECOCK MD

Table of content: DR. JOHN KEITH HEDGECOCK MD (NPI 1245295443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245295443 NPI number — DR. JOHN KEITH HEDGECOCK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEDGECOCK
Provider First Name:
JOHN
Provider Middle Name:
KEITH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1245295443
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1559
Provider Second Line Business Mailing Address:
DEPT 241
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74101-1559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-243-8418
Provider Business Mailing Address Fax Number:
918-663-2281

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2710 RIFE MEDICAL LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROGERS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72758-1452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-338-8000
Provider Business Practice Location Address Fax Number:
501-664-0302
Provider Enumeration Date:
04/19/2006

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: 2085R0202X , with the licence number:  C8265 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: C-8265 , 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: 134366001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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