1487168308 NPI number — DR Q PAIN & SPINE CLINIC, PA

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 1487168308 NPI number — DR Q PAIN & SPINE CLINIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR Q PAIN & SPINE CLINIC, PA
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:
1487168308
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5700 W MARKHAM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72205-3328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-227-0184
Provider Business Mailing Address Fax Number:
501-251-1975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 MCNEIL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72015-3345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-227-0184
Provider Business Practice Location Address Fax Number:
501-251-1975
Provider Enumeration Date:
11/30/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WELCH
Authorized Official First Name:
PAULA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
501-227-0184

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 179747002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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