1659389278 NPI number — LEE A. DAVIS, JR, MD, PA

Table of content: (NPI 1659389278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659389278 NPI number — LEE A. DAVIS, JR, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEE A. DAVIS, JR, MD, 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:
HEARTCARE CLINIC OF THE SOUTH
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:
1659389278
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7500 DOLLARWAY RD STE 301
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE HALL
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71602-3084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-850-0800
Provider Business Mailing Address Fax Number:
870-850-0801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7500 DOLLARWAY RD STE 301
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITE HALL
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71602-3084
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-850-0800
Provider Business Practice Location Address Fax Number:
870-850-0801
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
LEE
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
870-850-0800

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  E2239 , 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: 5C879 . This is a "BLUE CROSS CLINIC" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 150107002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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