Basic Information
| Provider Information | |||||||||
| NPI: | 1508195645 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SALINE PHYSICIAN SERVICES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SMH ANESTHESIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1635 | ||||||||
| Address2: | |||||||||
| City: | SEARCY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721451635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017714693 | ||||||||
| FaxNumber: | 5017714885 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720153353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017766381 | ||||||||
| FaxNumber: | 5017766350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2009 | ||||||||
| LastUpdateDate: | 01/28/2011 | ||||||||
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| AuthorizedOfficialLastName: | TITSWORTH | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, PHYSICIAN SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 5017766093 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SALINE PHYSICIAN SERVICES, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | AR | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 181231002 | 05 | AR | MEDICAID |