Basic Information
| Provider Information | |||||||||
| NPI: | 1043971096 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPA CITY PAIN MANAGEMENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11001 EXECUTIVE CENTER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722114393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018127215 | ||||||||
| FaxNumber: | 5018127207 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 PIPER ST STE L | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719018263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016510018 | ||||||||
| FaxNumber: | 5014636326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2022 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| AuthorizedOfficialLastName: | CRABTREE | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5016510018 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1760649388 | 01 | AR | NPI | OTHER |