Basic Information
| Provider Information | |||||||||
| NPI: | 1548239247 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ARKANSAS HEALTH GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PAULK FAMILY CLINIC/A BAPTIST HEALTH AFFILIATE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 11001 EXECUTIVE CENTER DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722114316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018127800 | ||||||||
| FaxNumber: | 5018127851 | ||||||||
| Practice Location | |||||||||
| Address1: | 1110 W VINE ST | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721507804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709425155 | ||||||||
| FaxNumber: | 8709428791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 02/09/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PAULK | ||||||||
| AuthorizedOfficialFirstName: | CLYDE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8709425155 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ARKANSAS HEALTH GROUP | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | C3204 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5901655 | 01 | AR | AETNA | OTHER | 128401002 | 05 | AR | MEDICAID | 14003000000 | 01 | AR | QUALCHOICE | OTHER | 770017602 | 01 | AR | BREASTCARE | OTHER |