Basic Information
| Provider Information | |||||||||
| NPI: | 1043495286 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ARKANSAS CANCER CLINIC - RADIATION ONCOLOGY, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7200 S HAZEL ST | ||||||||
| Address2: | |||||||||
| City: | PINE BLUFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716037836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705352800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7200 S HAZEL ST | ||||||||
| Address2: | |||||||||
| City: | PINE BLUFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716037836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705352800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2008 | ||||||||
| LastUpdateDate: | 01/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | COPE | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8705352800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | E3352 | AR | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1427148097 | 05 | AR | MEDICAID |