1700842994 NPI number — CRITTENDEN HOSPITAL ASSOCIATION

Table of content: (NPI 1700842994)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700842994 NPI number — CRITTENDEN HOSPITAL ASSOCIATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRITTENDEN HOSPITAL ASSOCIATION
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:
MID-SOUTH MULTI SPECIALTY CLINIC
Provider Other Organization Name Type Code:
3
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:
1700842994
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
228 W TYLER AVE
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
WEST MEMPHIS
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72301-4223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-735-4025
Provider Business Mailing Address Fax Number:
870-735-0570

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
228 W TYLER AVE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
WEST MEMPHIS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72301-4223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-735-4025
Provider Business Practice Location Address Fax Number:
870-735-0570
Provider Enumeration Date:
04/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCCORMICK
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
870-735-1500

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  N8431 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 5F794 . This is a "BLUE CROSS GROUP" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 166512002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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