Basic Information
| Provider Information | |||||||||
| NPI: | 1356319511 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARKANSAS HEALTH GROUP | ||||||||
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| OtherOrganizationName: | BAPTIST HEALTH FAMILY CLINIC MALVERN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11001 EXECUTIVE CENTER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722114393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018127800 | ||||||||
| FaxNumber: | 5018127777 | ||||||||
| Practice Location | |||||||||
| Address1: | 1234 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MALVERN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721045226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013379066 | ||||||||
| FaxNumber: | 5013325265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 04/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | RUSHER | ||||||||
| AuthorizedOfficialFirstName: | WILL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5018127500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5183071 | 01 | AR | AETNA | OTHER | 128273002 | 05 | AR | MEDICAID |