1063512051 NPI number — SOUTHARK EMS, LLC

Table of content: (NPI 1063512051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063512051 NPI number — SOUTHARK EMS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHARK EMS, 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:
1063512051
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 127
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMBURG
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71646-0127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-853-4800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
908 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMBURG
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71646-2722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-853-4800
Provider Business Practice Location Address Fax Number:
870-881-8989
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHAVER
Authorized Official First Name:
SHANNON
Authorized Official Middle Name:
Authorized Official Title or Position:
PRES.
Authorized Official Telephone Number:
870-853-4800

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  491 , 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: P00150820 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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