1376590083 NPI number — SOUTH ARKANSAS PATHOLOGY, PLLC

Table of content: (NPI 1376590083)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376590083 NPI number — SOUTH ARKANSAS PATHOLOGY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH ARKANSAS PATHOLOGY, PLLC
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:
DRS. TISDALE & CLARK PATHOLOGISTS
Provider Other Organization Name Type Code:
5
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:
1376590083
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 W 40TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINE BLUFF
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71603-6301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-541-7524
Provider Business Mailing Address Fax Number:
870-541-7543

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 W 40TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINE BLUFF
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71603-6301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-541-7524
Provider Business Practice Location Address Fax Number:
870-541-7543
Provider Enumeration Date:
05/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
870-541-7524

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 770093502 . This is a "BREASTCARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 57283 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 110247002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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