1477004471 NPI number — MAINLINE HEALTH SYSTEMS, INC

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 1477004471 NPI number — MAINLINE HEALTH SYSTEMS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAINLINE HEALTH SYSTEMS, INC
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:
DERMOTT SCHOOL 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:
1477004471
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 E SPEEDWAY ST
Provider Second Line Business Mailing Address:
PO BOX 509
Provider Business Mailing Address City Name:
DERMOTT
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71638-2317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-538-5414
Provider Business Mailing Address Fax Number:
870-538-5412

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 E SPEEDWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DERMOTT
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71638-2322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-538-3355
Provider Business Practice Location Address Fax Number:
855-811-4203
Provider Enumeration Date:
10/14/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NICHOLS
Authorized Official First Name:
GARY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
870-538-5414

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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