1538572227 NPI number — SOUTH CENTRAL MEDICAL SERVICES, P.A.

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 1538572227 NPI number — SOUTH CENTRAL MEDICAL SERVICES, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH CENTRAL MEDICAL SERVICES, P.A.
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:
6
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:
1538572227
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11020
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72917-1020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-434-4887
Provider Business Mailing Address Fax Number:
479-434-4955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3401 ROGERS AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
FORT SMITH
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72903-2956
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-434-4887
Provider Business Practice Location Address Fax Number:
479-434-4955
Provider Enumeration Date:
06/10/2014

Additional Information

Authorized Official

Authorized Official Last Name:
CARLSON
Authorized Official First Name:
CHESTER
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER/MEDICAL DIRECTOR
Authorized Official Telephone Number:
479-657-6888

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  E5307 , 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)





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