Provider Demographics
NPI:1124105416
Name:PSYCHIATRIC CLINIC OF HOT SPRINGS PA
Entity type:Organization
Organization Name:PSYCHIATRIC CLINIC OF HOT SPRINGS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:S
Authorized Official - Last Name:LANE
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:501-262-5614
Mailing Address - Street 1:PO BOX 6005
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71902-6005
Mailing Address - Country:US
Mailing Address - Phone:501-262-5614
Mailing Address - Fax:
Practice Address - Street 1:300 WERNER ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6406
Practice Address - Country:US
Practice Address - Phone:501-262-5614
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC54212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR121301002Medicaid
AR121301002Medicaid