Basic Information
| Provider Information | |||||||||
| NPI: | 1558708362 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARKANSAS RIVER EMERGENCY SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3114 CROASDAILE DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277052508 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4 HOSPITAL DR | ||||||||
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| City: | MORRILTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721104510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9732511132 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2013 | ||||||||
| LastUpdateDate: | 12/06/2019 | ||||||||
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| AuthorizedOfficialLastName: | KONDAS | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9732511132 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | AR | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | AR | MEDICAID |