1295700904 NPI number — DR. MICHELLE ECKERT MD

Table of content: DR. MICHELLE ECKERT MD (NPI 1295700904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295700904 NPI number — DR. MICHELLE ECKERT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ECKERT
Provider First Name:
MICHELLE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1295700904
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1609 W 40TH AVE
Provider Second Line Business Mailing Address:
SUITE 403
Provider Business Mailing Address City Name:
PINE BLUFF
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71603-6319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-534-4188
Provider Business Mailing Address Fax Number:
870-534-7964

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1609 W 40TH AVE
Provider Second Line Business Practice Location Address:
SUITE 403
Provider Business Practice Location Address City Name:
PINE BLUFF
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71603-6319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-534-4188
Provider Business Practice Location Address Fax Number:
870-534-7964
Provider Enumeration Date:
02/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  E2626 , 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: 142276001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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