1578045803 NPI number — BLUETAIL ARKANSAS PLLC

Table of content: (NPI 1578045803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578045803 NPI number — BLUETAIL ARKANSAS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUETAIL ARKANSAS PLLC
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:
1578045803
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
C/O BLUETAIL MEDICAL GROUP, LLC
Provider Second Line Business Mailing Address:
17300 NORTH OUTER 40 RD, STE 201
Provider Business Mailing Address City Name:
CHESTERFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63005-1364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-778-2900
Provider Business Mailing Address Fax Number:
636-778-2828

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9101 KANIS RD STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72205-6455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-778-2900
Provider Business Practice Location Address Fax Number:
636-778-2828
Provider Enumeration Date:
09/04/2018

Additional Information

Authorized Official

Authorized Official Last Name:
OLIVER
Authorized Official First Name:
KRISTIN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
636-778-2900

Provider Taxonomy Codes

  • Taxonomy code: 207QS0010X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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