Basic Information
Provider Information | |||||||||
NPI: | 1457353914 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LITTLE RIVER MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LITTLE RIVER MEMORIAL HOSPITAL EMERGENCY GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 451 W LOCKE ST | ||||||||
Address2: |   | ||||||||
City: | ASHDOWN | ||||||||
State: | AR | ||||||||
PostalCode: | 718223325 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8708985011 | ||||||||
FaxNumber: | 8708984172 | ||||||||
Practice Location | |||||||||
Address1: | 451 W LOCKE ST | ||||||||
Address2: |   | ||||||||
City: | ASHDOWN | ||||||||
State: | AR | ||||||||
PostalCode: | 718223325 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8708985011 | ||||||||
FaxNumber: | 8708984172 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/15/2005 | ||||||||
LastUpdateDate: | 05/03/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DEATON | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8708985011 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | AR4204 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   |
ID Information
ID | Type | State | Issuer | Description | 57601 | 01 | AR | BCBS ER PHYS GRP# | OTHER | 103216002 | 05 | AR |   | MEDICAID | 108625801 | 05 | TX |   | MEDICAID | 100699110B | 05 | OK |   | MEDICAID |