Basic Information
| Provider Information | |||||||||
| NPI: | 1700188117 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHILOH CLINIC PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 513 N. SHILOH STREET | ||||||||
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| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727644314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794199902 | ||||||||
| FaxNumber: | 4794199905 | ||||||||
| Practice Location | |||||||||
| Address1: | 307 N MAIN ST | ||||||||
| Address2: | APT. B | ||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727644340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793618694 | ||||||||
| FaxNumber: | 4793618694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2010 | ||||||||
| LastUpdateDate: | 11/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | KENDRICK | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER-PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 4794199902 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 103290001 | 05 | AR | MEDICAID | 124288001 | 05 | AR | MEDICAID |