Basic Information
| Provider Information | |||||||||
| NPI: | 1508082389 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WALKER INTERNAL MEDICINE CLINIC PA | ||||||||
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| OtherOrganizationName: | WALKER INTERNAL MEDICINE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11001 EXECUTIVE CENTER DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722114316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018127800 | ||||||||
| FaxNumber: | 5018127851 | ||||||||
| Practice Location | |||||||||
| Address1: | 9600 LILE DR | ||||||||
| Address2: | #220 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012191028 | ||||||||
| FaxNumber: | 5012191174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 04/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | BURNS | ||||||||
| AuthorizedOfficialFirstName: | SHANDRA | ||||||||
| AuthorizedOfficialMiddleName: | DENICE | ||||||||
| AuthorizedOfficialTitleorPosition: | TEAM COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5012191028 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | C8337 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 145041002 | 05 | AR | MEDICAID |