Basic Information
| Provider Information | |||||||||
| NPI: | 1215239702 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OLDENBERG INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 249 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702574110 | ||||||||
| FaxNumber: | 8702574112 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 WEST CHEROKEE VILLAGE MALL | ||||||||
| Address2: | |||||||||
| City: | CHEROKEE VILLAGE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702574110 | ||||||||
| FaxNumber: | 8702574112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2010 | ||||||||
| LastUpdateDate: | 12/03/2010 | ||||||||
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| AuthorizedOfficialLastName: | OLDENBERG | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8702574110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R3890 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.