1417285834 NPI number — MIDSOUTH MEDICINE & PSYCHIATRY CONSULTANTS PA

Table of content: (NPI 1417285834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417285834 NPI number — MIDSOUTH MEDICINE & PSYCHIATRY CONSULTANTS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDSOUTH MEDICINE & PSYCHIATRY CONSULTANTS 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:
1417285834
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 305
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLYTHEVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72316-0305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-763-2461
Provider Business Mailing Address Fax Number:
870-763-2466

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 N 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLYTHEVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72315-2712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-763-2461
Provider Business Practice Location Address Fax Number:
870-763-2466
Provider Enumeration Date:
11/23/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SALGUEIRO
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
901-634-6999

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  E1127 , 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: 132862001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 203956909 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".