Basic Information
| Provider Information | |||||||||
| NPI: | 1497784854 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LITTLE ROCK DIAGNOSTIC CLINIC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10001 LILE DR | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012278000 | ||||||||
| FaxNumber: | 5012215895 | ||||||||
| Practice Location | |||||||||
| Address1: | 10001 LILE DR | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012278000 | ||||||||
| FaxNumber: | 5012215895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 11/08/2017 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
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| AuthorizedOfficialTitleorPosition: | QUALITY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5012278000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 104282002 | 05 | AR | MEDICAID |