Basic Information
| Provider Information | |||||||||
| NPI: | 1730486556 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. EDWARD MERCY CLINIC, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MERCY CLINIC RIVER VALLEY THERAPY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11230 | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729171230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797096767 | ||||||||
| FaxNumber: | 4797096768 | ||||||||
| Practice Location | |||||||||
| Address1: | 3501 WE KNIGHT DRIVE | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729036248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797096700 | ||||||||
| FaxNumber: | 4797096709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2011 | ||||||||
| LastUpdateDate: | 12/02/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOODMAN | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | COLE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4793146100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 5G410 | 01 | AR | BLUE CROSS BLUE SHIELD | OTHER | 200199350J | 05 | OK | MEDICAID | DR1533 | 01 | AR | RAILROAD MEDICARE | OTHER |