Basic Information
| Provider Information | |||||||||
| NPI: | 1932174158 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY PRACTICE CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 786 | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721120786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705239337 | ||||||||
| FaxNumber: | 8702170312 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 MCLAIN ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721123638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705239337 | ||||||||
| FaxNumber: | 8702170312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 12/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | RILEY | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | VIRGINIA | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8705239337 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5C720 | 01 | AR | MEDICARE PROVIDER NUMBER | OTHER | 148627002 | 05 | AR | MEDICAID |