Basic Information
| Provider Information | |||||||||
| NPI: | 1952377517 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ARMISTEAD | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1223 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726532617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704247070 | ||||||||
| FaxNumber: | 8704246616 | ||||||||
| Practice Location | |||||||||
| Address1: | 624 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726532955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705081000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 08/13/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | E3046 | AR | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 146298001 | 05 | AR | MEDICAID |