Basic Information
| Provider Information | |||||||||
| NPI: | 1821084500 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAFFER | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 500 S UNIVERSITY AVE STE 500 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722055307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016644532 | ||||||||
| FaxNumber: | 5016634335 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 SAINT VINCENT CIR | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722055423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016644532 | ||||||||
| FaxNumber: | 5016634335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 03/19/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | E-3563 | AR | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | E-3563 | AR | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 71033532430 | 01 | AR | QUAL CHOICE | OTHER | 171973300 | 01 | AR | US DEPT. OF LABOR OWCP | OTHER | 5M462 | 01 | AR | BLUE CROSS BLUE SHIELD | OTHER | 050091825 | 01 | AR | RAILROAD MEDICARE (LRPM) | OTHER | 050091824 | 01 | AR | RAILROAD MEDICARE | OTHER | S02622 | 01 | AR | NOVASYS | OTHER | 149281001 | 05 | AR | MEDICAID | 03080012900 | 01 | AR | QUAL CHOICE (LRPM) | OTHER | 770248401 | 01 | AR | ARKANSAS BREASTCARE | OTHER |