Basic Information
| Provider Information | |||||||||
| NPI: | 1124549316 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DE QUEEN MEDICAL CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1306 W COLLIN RAYE DR | ||||||||
| Address2: | |||||||||
| City: | DE QUEEN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718322502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705844111 | ||||||||
| FaxNumber: | 8705844100 | ||||||||
| Practice Location | |||||||||
| Address1: | 1314 W COLLIN RAYE DR | ||||||||
| Address2: | |||||||||
| City: | DE QUEEN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718322135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8706422273 | ||||||||
| FaxNumber: | 8706422162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2017 | ||||||||
| LastUpdateDate: | 06/28/2017 | ||||||||
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| AuthorizedOfficialLastName: | ICENHOWER | ||||||||
| AuthorizedOfficialFirstName: | JERRAMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8705840272 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | RN, BSN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.