1902865579 NPI number — OAK PARK MEDICAL C,LINIC, P.A.

Table of content: (NPI 1902865579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902865579 NPI number — OAK PARK MEDICAL C,LINIC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OAK PARK MEDICAL C,LINIC, P.A.
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:
1902865579
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2335
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATESVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72503-2335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-793-6887
Provider Business Mailing Address Fax Number:
870-793-8085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 WHITE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATESVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72501-9467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-793-6887
Provider Business Practice Location Address Fax Number:
870-793-8085
Provider Enumeration Date:
03/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MOODY
Authorized Official First Name:
LACKEY
Authorized Official Middle Name:
GENE
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
870-793-9887

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  C-4126 , 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: 57250 . This is a "BLUE CROSS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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