Basic Information
| Provider Information | |||||||||
| NPI: | 1144493529 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRAWFORD KIDS CARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2925 ALMA HWY STE C1 | ||||||||
| Address2: | |||||||||
| City: | VAN BUREN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729565063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794715454 | ||||||||
| FaxNumber: | 4794715473 | ||||||||
| Practice Location | |||||||||
| Address1: | 2925 ALMA HWY STE C1 | ||||||||
| Address2: | |||||||||
| City: | VAN BUREN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729565063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794715454 | ||||||||
| FaxNumber: | 4794715473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2008 | ||||||||
| LastUpdateDate: | 04/08/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | PEYTON | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4794715454 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | E1002 | AR | Y | Managed Care Organizations | Preferred Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | E1002 | 01 | AR | STATE LICENSE NO. | OTHER | F78642 | 01 | AR | UPIN | OTHER |