Basic Information
Provider Information | |||||||||
NPI: | 1295774917 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MERCY HOSPITAL WALDRON | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MERCY FAMILY MEDICINE - MANSFIELD | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5401 ELLSWORTH RD | ||||||||
Address2: |   | ||||||||
City: | FORT SMITH | ||||||||
State: | AR | ||||||||
PostalCode: | 729033219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4793141101 | ||||||||
FaxNumber: | 4793144740 | ||||||||
Practice Location | |||||||||
Address1: | 100 N WALNUT AVE STE A | ||||||||
Address2: |   | ||||||||
City: | MANSFIELD | ||||||||
State: | AR | ||||||||
PostalCode: | 729443522 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4799284404 | ||||||||
FaxNumber: | 4799284414 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2006 | ||||||||
LastUpdateDate: | 02/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CLOUSE DAY | ||||||||
AuthorizedOfficialFirstName: | SHERRY | ||||||||
AuthorizedOfficialMiddleName: | LYNN | ||||||||
AuthorizedOfficialTitleorPosition: | VP FINANCE MERCY CAH | ||||||||
AuthorizedOfficialTelephone: | 4178208439 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | AR4196 | AR | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 5F644 | 01 | AR | BLUE CROSS BLUESHIELD | OTHER | 162620729 | 05 | AR |   | MEDICAID |