Basic Information
Provider Information | |||||||||
NPI: | 1538522347 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTRAL ARKANSAS SPINE SPECIALISTS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5 MEDICAL PARK DR | ||||||||
Address2: | STE 308 | ||||||||
City: | BENTON | ||||||||
State: | AR | ||||||||
PostalCode: | 720153729 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5017766252 | ||||||||
FaxNumber: | 5017766271 | ||||||||
Practice Location | |||||||||
Address1: | 5 MEDICAL PARK DR | ||||||||
Address2: | STE 308 | ||||||||
City: | BENTON | ||||||||
State: | AR | ||||||||
PostalCode: | 720153729 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5017766252 | ||||||||
FaxNumber: | 5017766271 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/30/2016 | ||||||||
LastUpdateDate: | 03/30/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KIPP | ||||||||
AuthorizedOfficialFirstName: | ANNA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHYSICIAN SERVICES | ||||||||
AuthorizedOfficialTelephone: | 5017766093 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SALINE PHYSICIAN SERVICES | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.