Basic Information
| Provider Information | |||||||||
| NPI: | 1619902574 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCDONALD | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 MARGEAUX DR | ||||||||
| Address2: | |||||||||
| City: | MAUMELLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721137248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019200158 | ||||||||
| FaxNumber: | 5012245460 | ||||||||
| Practice Location | |||||||||
| Address1: | 10014 N RODNEY PARHAM RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012245454 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 10/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1073 | AR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 148049742 | 05 | AR | MEDICAID |