1023902921 NPI number — INFECTIOUS DISEASES SERVICES OF ARKANSAS LLC

Table of content: (NPI 1023902921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023902921 NPI number — INFECTIOUS DISEASES SERVICES OF ARKANSAS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INFECTIOUS DISEASES SERVICES OF ARKANSAS LLC
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:
1023902921
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
INFECTIOUS DISEASES SERVICES OF ARKANSAS LLC
Provider Second Line Business Mailing Address:
2316 DUNDEE DRIVE
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-652-7973
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
INFECTIOUS DISEASES SERVICES OF ARKANSAS, LLC
Provider Second Line Business Practice Location Address:
3416 OLD GREENWOOD RD, SUITE #B
Provider Business Practice Location Address City Name:
FORT SMITH
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-652-7973
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/05/2025

Additional Information

Authorized Official

Authorized Official Last Name:
KHAIRY
Authorized Official First Name:
RAED
Authorized Official Middle Name:
N.
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
479-652-7973

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 168560001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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