Basic Information
| Provider Information | |||||||||
| NPI: | 1730128935 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | PATRIC | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6830 PEACH DR | ||||||||
| Address2: | |||||||||
| City: | ALMA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729217595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796326326 | ||||||||
| FaxNumber: | 4796325122 | ||||||||
| Practice Location | |||||||||
| Address1: | 7301 ROGERS AVE | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729034100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793146000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 12/30/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | E-2148 | AR | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100142410B | 05 | OK | MEDICAID | 137508001 | 05 | AR | MEDICAID |