1376517177 NPI number — NORTHEAST ARKANSAS CLINIC, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376517177 NPI number — NORTHEAST ARKANSAS CLINIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST ARKANSAS CLINIC, 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:
NEA CLINIC
Provider Other Organization Name Type Code:
3
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:
1376517177
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1960
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72403-1960
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-934-5101
Provider Business Mailing Address Fax Number:
870-932-3608

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1835 GRANT AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-934-5101
Provider Business Practice Location Address Fax Number:
870-932-3608
Provider Enumeration Date:
02/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
ERROL
Authorized Official Middle Name:
SCOT
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
870-934-5803

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 139864002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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