Basic Information
| Provider Information | |||||||||
| NPI: | 1245345958 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHARLES ROY KLEPPER ET AL PTRS | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MAIN STREET MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726012912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707413592 | ||||||||
| FaxNumber: | 8707417733 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726012912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707413592 | ||||||||
| FaxNumber: | 8707417733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 04/30/2014 | ||||||||
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| AuthorizedOfficialLastName: | KLEPPER | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8707413592 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5B704 | 01 | AR | ARK. BLUE SHIELD | OTHER | 127780002 | 05 | AR | MEDICAID |