Basic Information
Provider Information
NPI: 1144559287
EntityType: 2
ReplacementNPI:  
OrganizationName: SALINE PHYSICIAN SERVICES, LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: BRYANT MEDICAL CLINIC
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 1615
Address2:  
City: SEARCY
State: AR
PostalCode: 721451615
CountryCode: US
TelephoneNumber: 5016530353
FaxNumber: 5016530347
Practice Location
Address1: 319 BRYANT AVE
Address2: SUITE 1
City: BRYANT
State: AR
PostalCode: 720223815
CountryCode: US
TelephoneNumber: 5016530353
FaxNumber: 5016530347
Other Information
ProviderEnumerationDate: 12/21/2009
LastUpdateDate: 10/12/2015
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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X ARY193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal Medicine 

ID Information
IDTypeStateIssuerDescription
18216400205AR MEDICAID


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