1710935218 NPI number — DR. MARY MOORE EKDAHL PHD

Table of content: DR. MARY MOORE EKDAHL PHD (NPI 1710935218)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710935218 NPI number — DR. MARY MOORE EKDAHL PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EKDAHL
Provider First Name:
MARY
Provider Middle Name:
MOORE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOORE
Provider Other First Name:
MARY
Provider Other Middle Name:
CATHERINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710935218
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4004 MCCAIN BLVD
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
NORTH LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72116-8057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-812-4268
Provider Business Mailing Address Fax Number:
501-812-4286

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4004 MCCAIN BLVD
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
NORTH LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72116-8057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-812-4268
Provider Business Practice Location Address Fax Number:
501-812-4286
Provider Enumeration Date:
05/05/2006

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: 103TC0700X , with the licence number:  964P , 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: 139320719 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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