Basic Information
| Provider Information | |||||||||
| NPI: | 1023346202 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY CLINIC FORT SMITH COMMUNITIES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MERCY CLINIC CARDIOLOGY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 S 74TH ST | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729035156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793141101 | ||||||||
| FaxNumber: | 4793144704 | ||||||||
| Practice Location | |||||||||
| Address1: | 7001 ROGERS AVE | ||||||||
| Address2: | SUITE 401A | ||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729034073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793144650 | ||||||||
| FaxNumber: | 4794529459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2009 | ||||||||
| LastUpdateDate: | 01/16/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOODMAN | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | COLE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4793147568 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.