Provider Demographics
NPI:1104106426
Name:SHANE HIGGINBOTHAM MD PA
Entity type:Organization
Organization Name:SHANE HIGGINBOTHAM MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:OVERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-337-9994
Mailing Address - Street 1:1580 TANNER ST
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72104-2023
Mailing Address - Country:US
Mailing Address - Phone:501-337-9994
Mailing Address - Fax:501-337-9964
Practice Address - Street 1:1580 TANNER ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:AR
Practice Address - Zip Code:72104-2023
Practice Address - Country:US
Practice Address - Phone:501-337-9994
Practice Address - Fax:501-337-9964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-17
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0968207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR205795002Medicaid