Basic Information
| Provider Information | |||||||||
| NPI: | 1649384835 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARKANSAS HEALTH GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BAPTIST HEALTH FAMILY CLINIC ARKADELPHIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 416 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ARKADELPHIA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719236144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702462431 | ||||||||
| FaxNumber: | 8702462434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 02/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | BALAY | ||||||||
| AuthorizedOfficialFirstName: | EULA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8702462431 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAPTIST HEALTH FAMILY CLINIC ARKADELPHIA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 146856002 | 05 | AR | MEDICAID | 7233256 | 01 | AR | AETNA | OTHER |