Basic Information
| Provider Information | |||||||||
| NPI: | 1952316390 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FARMINGTON FAMILY MEDICAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 199 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727303077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792671001 | ||||||||
| FaxNumber: | 4792671026 | ||||||||
| Practice Location | |||||||||
| Address1: | 199 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727303077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792671001 | ||||||||
| FaxNumber: | 4792671026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 02/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | ABDIN | ||||||||
| AuthorizedOfficialFirstName: | JAMAL | ||||||||
| AuthorizedOfficialMiddleName: | ZIAD | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4792671001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E3510 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 156125002 | 05 | AR | MEDICAID |