Basic Information
| Provider Information | |||||||||
| NPI: | 1558492017 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH CENTRAL GI, LLC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 124 SAWTOOTH OAK ST | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719017160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016237800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 124 SAWTOOTH OAK ST | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719017160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016237800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 04/04/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLACKSTOCK | ||||||||
| AuthorizedOfficialFirstName: | TERRI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5016237800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 126541001 | 05 | AR | MEDICAID | 146525002 | 05 | AR | MEDICAID |