Basic Information
| Provider Information | |||||||||
| NPI: | 1942243787 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REEL FAMILY FOOT CLINIC, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9178 | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728119178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799684273 | ||||||||
| FaxNumber: | 4799681363 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 E PARKWAY DR | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728013913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4798802600 | ||||||||
| FaxNumber: | 4798808076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 08/18/2009 | ||||||||
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| AuthorizedOfficialLastName: | REEL | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | CARROLL | ||||||||
| AuthorizedOfficialTitleorPosition: | DPM | ||||||||
| AuthorizedOfficialTelephone: | 4798802600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 215 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 159972748 | 05 | AR | MEDICAID |