Basic Information
| Provider Information | |||||||||
| NPI: | 1972547099 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEUROSURGERY ARKANSAS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9601 BAPTIST HEALTH DRIVE | ||||||||
| Address2: | SUITE 750 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012240200 | ||||||||
| FaxNumber: | 5012242292 | ||||||||
| Practice Location | |||||||||
| Address1: | 9601 BAPTIST HEALTH DRIVE | ||||||||
| Address2: | SUITE 750 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012240200 | ||||||||
| FaxNumber: | 5012242292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 08/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | MCWILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | KYLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINIC MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5012240200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | SR. | ||||||||
| AuthorizedOfficialCredential: | M.H.H. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | E2467 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 7182611 | 01 | AR | AETNA | OTHER | 155462002 | 05 | AR | MEDICAID |