Basic Information
| Provider Information | |||||||||
| NPI: | 1316188774 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARKANSAS HEALTH GROUP | ||||||||
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| OtherOrganizationName: | BAPTIST HEALTH WOUND CARE AND HYPERBARIC CENTER NORTH LITTLE ROCK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11001 EXECUTIVE CENTER DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722114316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018127800 | ||||||||
| FaxNumber: | 5018127851 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 SPRINGHILL DR | ||||||||
| Address2: | |||||||||
| City: | NORTH LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721172922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012023638 | ||||||||
| FaxNumber: | 5012023639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2009 | ||||||||
| LastUpdateDate: | 07/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | TITSWORTH | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | RPA | ||||||||
| AuthorizedOfficialTelephone: | 5018127587 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0005X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Undersea and Hyperbaric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 176934002 | 05 | AR | MEDICAID |