Basic Information
| Provider Information | |||||||||
| NPI: | 1306191762 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AHEC FAMILY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 612 S 12TH ST | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729014702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797852431 | ||||||||
| FaxNumber: | 4794947787 | ||||||||
| Practice Location | |||||||||
| Address1: | 612 S 12TH ST | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729014702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797852431 | ||||||||
| FaxNumber: | 4794947787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2012 | ||||||||
| LastUpdateDate: | 07/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | RICHARDSON | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINIC MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4797852431 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 159360762 | 05 | AR | MEDICAID |