Basic Information
| Provider Information | |||||||||
| NPI: | 1003877853 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARKANSAS ALLERGY & ASTHMA CLINIC, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 55090 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722155090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012275210 | ||||||||
| FaxNumber: | 5013121592 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 EXECUTIVE CENTER CT | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722114375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012275210 | ||||||||
| FaxNumber: | 5013121592 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 03/06/2019 | ||||||||
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| AuthorizedOfficialLastName: | WELLS | ||||||||
| AuthorizedOfficialFirstName: | PAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5012275210 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 104277002 | 05 | AR | MEDICAID |