Basic Information
| Provider Information | |||||||||
| NPI: | 1558678276 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SALINE PHYSICIAN SERVICES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SALINE SURGICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 MEDICAL PARK DR | ||||||||
| Address2: | SUITE GL2 | ||||||||
| City: | BENTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720153729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017784862 | ||||||||
| FaxNumber: | 5017784685 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 MEDICAL PARK DR | ||||||||
| Address2: | SUITE GL2 | ||||||||
| City: | BENTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720153729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017784862 | ||||||||
| FaxNumber: | 5017784685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2010 | ||||||||
| LastUpdateDate: | 10/09/2013 | ||||||||
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| AuthorizedOfficialLastName: | TITSWORTH | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, PHYSICIAN SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 5017766093 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SALINE COUNTY MEDICAL SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1558678276 | 01 | AR | BCBS | OTHER |