1821148586 NPI number — PINE BLUFF SURGICAL CLINIC, INC

Table of content: (NPI 1821148586)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821148586 NPI number — PINE BLUFF SURGICAL CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINE BLUFF SURGICAL CLINIC, 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:
PROFESSIONAL MEDICAL REVIEW, INC
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:
1821148586
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
316 W 6TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINE BLUFF
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71601-4217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-850-6053
Provider Business Mailing Address Fax Number:
870-850-6482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
316 W 6TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINE BLUFF
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71601-4217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-850-6053
Provider Business Practice Location Address Fax Number:
870-850-6482
Provider Enumeration Date:
01/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERSON
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
VAIDEN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
870-850-6053

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  R1682 , 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: 103023002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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