Basic Information
Provider Information | |||||||||
NPI: | 1720309511 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EDDY | ||||||||
FirstName: | DERRICK | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 507 | ||||||||
Address2: |   | ||||||||
City: | LOWELL | ||||||||
State: | AR | ||||||||
PostalCode: | 727450507 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9136474100 | ||||||||
FaxNumber: | 9136474120 | ||||||||
Practice Location | |||||||||
Address1: | 2601 GENE GEORGE BLVD | ||||||||
Address2: |   | ||||||||
City: | SPRINGDALE | ||||||||
State: | AR | ||||||||
PostalCode: | 727620845 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4797256800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2010 | ||||||||
LastUpdateDate: | 06/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | C002970 | AR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 1720309511 | 01 | AR | TRICARE SOUTH | OTHER | P01278937 | 01 | AR | RAILROAD | OTHER | 5UU07 | 01 | AR | BCBS ARKANSAS | OTHER | 198801001 | 05 | AR |   | MEDICAID | 200494180A | 05 | OK |   | MEDICAID | 1720309511 | 05 | MO |   | MEDICAID |