1295281293 NPI number — ARKANSAS LIVER AND GASTROENTEROLOGY, P.A.

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 1295281293 NPI number — ARKANSAS LIVER AND GASTROENTEROLOGY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARKANSAS LIVER AND GASTROENTEROLOGY, P.A.
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:
1295281293
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3416 OLD GREENWOOD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72903-5462
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-242-2888
Provider Business Mailing Address Fax Number:
479-242-2889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1605 WEST MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUSSELLVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-242-2888
Provider Business Practice Location Address Fax Number:
479-242-2889
Provider Enumeration Date:
08/30/2016

Additional Information

Authorized Official

Authorized Official Last Name:
COLUCCINO
Authorized Official First Name:
SARAH
Authorized Official Middle Name:
JESSICA-ELISE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
479-242-2888

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , 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)





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