Basic Information
| Provider Information | |||||||||
| NPI: | 1770584393 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARKANSAS VALLEY ANESTHESIA ASSOCIATES, P. A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1351 | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728111351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776497812 | ||||||||
| FaxNumber: | 9183922941 | ||||||||
| Practice Location | |||||||||
| Address1: | 1808 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728012724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799682841 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5014548336 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 207L00000X | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 113665002 | 05 | AR | MEDICAID | 770090702 | 01 | AR | AR BREASTCARE | OTHER | CC5970 | 01 | RR MEDICARE | OTHER | 57607 | 01 | AR | BLUE CROSS BLUE SHIELD AR | OTHER |