1942473079 NPI number — SPECIALIZED PHYSICAL MEDICINE AND REHABILITIAN CLINICS PC

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 1942473079 NPI number — SPECIALIZED PHYSICAL MEDICINE AND REHABILITIAN CLINICS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECIALIZED PHYSICAL MEDICINE AND REHABILITIAN CLINICS PC
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:
6
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:
1942473079
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
520 W RIVENDALE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65810-3122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-886-0310
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 N MAIN ST
Provider Second Line Business Practice Location Address:
SUIT C
Provider Business Practice Location Address City Name:
HARRISON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72601-3535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-343-1307
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MOHSEN
Authorized Official First Name:
ALY
Authorized Official Middle Name:
MOHAMED
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
417-886-0310

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X , with the licence number:  E-3715 , 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)





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