Provider Demographics
NPI:1194730077
Name:WESTERN ARKANSAS PLASTIC & RECONSTRUCTIVE SURGERY CENTER
Entity type:Organization
Organization Name:WESTERN ARKANSAS PLASTIC & RECONSTRUCTIVE SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:479-709-8300
Mailing Address - Street 1:PO BOX 10810
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-0810
Mailing Address - Country:US
Mailing Address - Phone:479-709-8300
Mailing Address - Fax:479-709-8315
Practice Address - Street 1:8101 MCCLURE DR STE 301
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72916-6056
Practice Address - Country:US
Practice Address - Phone:479-709-8300
Practice Address - Fax:479-709-8315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0847208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR130121001Medicaid
OK100000480AMedicaid
ARG18935Medicare UPIN
AR130121001Medicaid