Basic Information
Provider Information | |||||||||
NPI: | 1497790042 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BAPTIST HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BAPTIST HEALTH MEDICAL CENTER-NORTH LITTLE ROCK | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9601 BAPTIST HEALTH DRIVE | ||||||||
Address2: |   | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 72205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5012022080 | ||||||||
FaxNumber: | 5012021722 | ||||||||
Practice Location | |||||||||
Address1: | 3333 SPRINGHILL DR | ||||||||
Address2: |   | ||||||||
City: | NORTH LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 721172922 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5012022274 | ||||||||
FaxNumber: | 5012021722 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/18/2006 | ||||||||
LastUpdateDate: | 03/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WELLS | ||||||||
AuthorizedOfficialFirstName: | TROY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5012022080 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | AR3828 | AR | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 10036 | 01 | AR | BCBS PROV NUMBER | OTHER | 106664105 | 05 | AR |   | MEDICAID |