1710225545 NPI number — BAPTIST HEALTH FAMILY CLINIC PROTHO

Table of content: (NPI 1710225545)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710225545 NPI number — BAPTIST HEALTH FAMILY CLINIC PROTHO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAPTIST HEALTH FAMILY CLINIC PROTHO
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:
1710225545
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11001 EXECUTIVE CENTER DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72211-4316
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-812-7512
Provider Business Mailing Address Fax Number:
501-812-7507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5207 E BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72117-4029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-945-2033
Provider Business Practice Location Address Fax Number:
501-945-2303
Provider Enumeration Date:
01/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
RUSHER
Authorized Official First Name:
WILL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
501-812-7512

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  R2917 , 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: 1048721002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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