Basic Information
| Provider Information | |||||||||
| NPI: | 1669619987 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL ARKANSAS VASCULAR ASSOCIATES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9601 LILE DR | ||||||||
| Address2: | 700 MEDICAL TOWERS BUILDING I | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012191970 | ||||||||
| FaxNumber: | 5012191944 | ||||||||
| Practice Location | |||||||||
| Address1: | 9601 LILE DR | ||||||||
| Address2: | 700 MEDICAL TOWERS BUILDING I | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012191970 | ||||||||
| FaxNumber: | 5012191944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2009 | ||||||||
| LastUpdateDate: | 08/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | ALBERTY | ||||||||
| AuthorizedOfficialFirstName: | BRETT | ||||||||
| AuthorizedOfficialMiddleName: | LANE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/SURGEON | ||||||||
| AuthorizedOfficialTelephone: | 5012191970 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | E-5295 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | DO9632 | 01 | AR | RAILROAD MEDICARE | OTHER |