1982193975 NPI number — MONTICELLO MEDICAL CLINIC, PLC

Table of content: (NPI 1982193975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982193975 NPI number — MONTICELLO MEDICAL CLINIC, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONTICELLO MEDICAL CLINIC, PLC
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:
1982193975
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
906 ROBERTS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTICELLO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71655-5724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-367-6867
Provider Business Mailing Address Fax Number:
870-367-1461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1306 N. LINCOLN AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAR CITY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-628-1388
Provider Business Practice Location Address Fax Number:
870-628-1347
Provider Enumeration Date:
05/04/2018

Additional Information

Authorized Official

Authorized Official Last Name:
SIMON
Authorized Official First Name:
SYLVIA
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
870-367-6867

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MC-1891 , 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: 139812002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com