Provider Demographics
NPI:1194868281
Name:NORTHWEST ARKANSAS PODIATRY CENTER, INC.
Entity type:Organization
Organization Name:NORTHWEST ARKANSAS PODIATRY CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHETSAMONE
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:XAYSANASY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:479-251-9200
Mailing Address - Street 1:125 W SUNBRIDGE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-1899
Mailing Address - Country:US
Mailing Address - Phone:479-251-9200
Mailing Address - Fax:
Practice Address - Street 1:125 W SUNBRIDGE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1899
Practice Address - Country:US
Practice Address - Phone:479-251-9200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR193213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C648OtherBLUECROSS BLUESHIELD
AR146684748Medicaid
AR4738950001Medicare NSC
AR146684748Medicaid
AR5C648OtherBLUECROSS BLUESHIELD