1285105957 NPI number — MAINLINE HEALTH SYSTEMS, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285105957 NPI number — MAINLINE HEALTH SYSTEMS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAINLINE HEALTH SYSTEMS, 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:
Provider Other Organization Name Type Code:
6
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:
1285105957
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 509
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DERMOTT
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71638-0509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-538-5414
Provider Business Mailing Address Fax Number:
870-538-5412

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 SYCAMORE ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RISON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-325-6255
Provider Business Practice Location Address Fax Number:
870-663-4112
Provider Enumeration Date:
12/06/2018

Additional Information

Authorized Official

Authorized Official Last Name:
NICHOLS
Authorized Official First Name:
GARY
Authorized Official Middle Name:
ALLAN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
870-942-3000

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 236578749 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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