Basic Information
| Provider Information | |||||||||
| NPI: | 1861443970 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARKER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | Y | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 TOWSON AVE | ||||||||
| Address2: | SUITE L0LA | ||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729017994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797097000 | ||||||||
| FaxNumber: | 4797097051 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 TOWSON AVE | ||||||||
| Address2: | SUITE L0LA | ||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729017994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797097000 | ||||||||
| FaxNumber: | 4797097051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5U331 | AR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 5U331 | 01 | AR | AR BLUE CROSS BLUE SHIELD | OTHER |