1871751198 NPI number — SPRINGDALE FOOT SPECIALIST PA

Table of content: (NPI 1871751198)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871751198 NPI number — SPRINGDALE FOOT SPECIALIST PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPRINGDALE FOOT SPECIALIST 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:
1871751198
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1213 S THOMPSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGDALE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72764-6313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-751-3656
Provider Business Mailing Address Fax Number:
479-750-2221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1213 S THOMPSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGDALE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72764-6313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-751-3656
Provider Business Practice Location Address Fax Number:
479-750-2221
Provider Enumeration Date:
05/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PINKERTON
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
479-751-3656

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  69 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 121 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 106361717 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200052700A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 442460675 . This is a "MEDICARE - OK" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 56364 . This is a "PTAN" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 480032388 . This is a "MCRR" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com