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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208D00000XAR4204ARY193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansGeneral Practice 

ID Information
IDTypeStateIssuerDescription
5760101ARBCBS ER PHYS GRP#OTHER
10321600205AR MEDICAID
10862580105TX MEDICAID
100699110B05OK MEDICAID


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