Basic Information
| Provider Information | |||||||||
| NPI: | 1801951215 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARKANSAS HEALTH GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BAPTIST HEALTH OCCUPATIONAL HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11001 EXECUTIVE CENTER DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722114316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018127500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6800 LINDSEY RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722063877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5014901633 | ||||||||
| FaxNumber: | 5014900770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 05/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | TITSWORTH | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGEMENT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5018127512 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ARKANSAS HEALTH GROUP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | E0002 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 165453002 | 05 | AR | MEDICAID |