Basic Information
| Provider Information | |||||||||
| NPI: | 1891926796 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVANCED WOUND CARE & HYPERBARICS, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 15453 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722315453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012023638 | ||||||||
| FaxNumber: | 5012023639 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 SPRINGHILL DR | ||||||||
| Address2: | SUITE 2002 | ||||||||
| City: | NORTH LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721172922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012023638 | ||||||||
| FaxNumber: | 5012023639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2009 | ||||||||
| LastUpdateDate: | 10/05/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DRISKILL | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/SECRETARY/TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 5012023638 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0005X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Undersea and Hyperbaric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5G169 | 01 | AR | BLUE CROSS BLUE SHIELD OF ARKANSAS | OTHER | 179015002 | 05 | AR | MEDICAID |