Basic Information
Provider Information | |||||||||
NPI: | 1295932820 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BAPTIST HEALTH HOSPITALS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BAPTIST HEALTH FAMILY CLINIC DEWITT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11001 EXECUTIVE CENTER DRIVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 722114393 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5018127800 | ||||||||
FaxNumber: | 5018127777 | ||||||||
Practice Location | |||||||||
Address1: | 1703 S WHITEHEAD DR | ||||||||
Address2: |   | ||||||||
City: | DE WITT | ||||||||
State: | AR | ||||||||
PostalCode: | 720422911 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8709460300 | ||||||||
FaxNumber: | 8709460303 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2007 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WELLS | ||||||||
AuthorizedOfficialFirstName: | TROY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5012022080 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | BAPTIST HEALTH HOSPITALS | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   | AR | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 201481729 | 05 | AR |   | MEDICAID | 136428729 | 05 | AR |   | MEDICAID |