1578591129 NPI number — SALEM FAMILY PRACTICE 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 1578591129 NPI number — SALEM FAMILY PRACTICE CLINIC,PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SALEM FAMILY PRACTICE 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:
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:
1578591129
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6640 CONGO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72019-6913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-794-4110
Provider Business Mailing Address Fax Number:
501-316-9360

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6640 CONGO RD
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:
72019-6913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-794-4110
Provider Business Practice Location Address Fax Number:
501-316-9360
Provider Enumeration Date:
06/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCGARRY
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PHYSICIAN OWNER
Authorized Official Telephone Number:
501-794-4110

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  MC1718 , 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: 5F075 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 5F075 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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