1962642900 NPI number — MARTIN BOWEN HEFLEY KNEE & SPORTS MED. CTR.

Table of content: (NPI 1962642900)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962642900 NPI number — MARTIN BOWEN HEFLEY KNEE & SPORTS MED. CTR.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARTIN BOWEN HEFLEY KNEE & SPORTS MED. CTR.
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:
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:
1962642900
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 SAINT VINCENT CIR
Provider Second Line Business Mailing Address:
SUITE 401
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72205-5412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-663-4320
Provider Business Mailing Address Fax Number:
501-978-1452

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 SAINT VINCENT CIR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72205-5412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-663-4320
Provider Business Practice Location Address Fax Number:
501-978-1452
Provider Enumeration Date:
03/04/2009

Additional Information

Authorized Official

Authorized Official Last Name:
STEWART
Authorized Official First Name:
TERESA
Authorized Official Middle Name:
DARLENE
Authorized Official Title or Position:
CLINIC ADMINISTRATOR
Authorized Official Telephone Number:
501-663-6455

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 152501742 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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