1649357690 NPI number — KEVIN L ST. CLAIR M.D.

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 1649357690 NPI number — KEVIN L ST. CLAIR M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ST. CLAIR
Provider First Name:
KEVIN
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1649357690
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4375 N VANTAGE DR
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72703-4982
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-443-5100
Provider Business Mailing Address Fax Number:
479-443-5117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4375 N VANTAGE DR
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72703-4982
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-443-5100
Provider Business Practice Location Address Fax Number:
479-443-5117
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  R4149 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X , with the licence number: R-4149 , 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: 119113001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 16085000000 . This is a "QUALCHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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