Basic Information
| Provider Information | |||||||||
| NPI: | 1003970872 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMERIS OF OSCEOLA,LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SMC REGIONAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 327 | ||||||||
| Address2: | |||||||||
| City: | BLYTHEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723160327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708387300 | ||||||||
| FaxNumber: | 8708387100 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 W LEE AVE | ||||||||
| Address2: | |||||||||
| City: | OSCEOLA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723703001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705637200 | ||||||||
| FaxNumber: | 8708387100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LYNN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8708387462 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | AR4260 | AR | Y | Hospital Units | Medicare Defined Swing Bed Unit |
No ID Information.