Basic Information
| Provider Information | |||||||||
| NPI: | 1407845951 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH ARKANSAS ORTHOPAEDICS AND SPORTS MEDICINE CENTER PLLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTH ARKANSAS ORTHOPAEDICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10730 | ||||||||
| Address2: | |||||||||
| City: | EL DORADO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717300028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708621144 | ||||||||
| FaxNumber: | 8708640782 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 VINE ST | ||||||||
| Address2: | |||||||||
| City: | EL DORADO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717306700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708621144 | ||||||||
| FaxNumber: | 8708640782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 12/01/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | KATHEY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8708621144 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 200039405 | 01 | AR | UNITED/RAILROAD MEDICARE | OTHER | 200039406 | 01 | AR | UNITED/RAILROAD MEDICARE | OTHER | 200031980 | 01 | AR | UNITED/RAILROAD MEDICARE | OTHER | 141689002 | 05 | AR | MEDICAID |