Basic Information
Provider Information | |||||||||
NPI: | 1114950433 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SALINE PHYSICIAN SERVICES, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SALINE MEMORIAL HOSPITALIST GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1635 | ||||||||
Address2: |   | ||||||||
City: | SEARCY | ||||||||
State: | AR | ||||||||
PostalCode: | 721451635 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5017766252 | ||||||||
FaxNumber: | 5017766271 | ||||||||
Practice Location | |||||||||
Address1: | 1 MEDICAL PARK DR | ||||||||
Address2: |   | ||||||||
City: | BENTON | ||||||||
State: | AR | ||||||||
PostalCode: | 720153353 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5017767130 | ||||||||
FaxNumber: | 5017766695 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2006 | ||||||||
LastUpdateDate: | 03/30/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TITSWORTH | ||||||||
AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, PHYSICIAN SERVICES | ||||||||
AuthorizedOfficialTelephone: | 5017766093 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SALINE COUNTY MEDICAL SYSTEM | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 158019002 | 05 | AR |   | MEDICAID | 5F357 | 01 | AR | BCBS | OTHER |