Provider Demographics
NPI:1285047688
Name:GRAND PRAIRIE MEDICAL GROUP, PLLC
Entity type:Organization
Organization Name:GRAND PRAIRIE MEDICAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-791-9355
Mailing Address - Street 1:1012 E 22ND ST
Mailing Address - Street 2:
Mailing Address - City:STUTTGART
Mailing Address - State:AR
Mailing Address - Zip Code:72160-6825
Mailing Address - Country:US
Mailing Address - Phone:870-672-0911
Mailing Address - Fax:870-672-0914
Practice Address - Street 1:1012 E 22ND ST
Practice Address - Street 2:
Practice Address - City:STUTTGART
Practice Address - State:AR
Practice Address - Zip Code:72160-6825
Practice Address - Country:US
Practice Address - Phone:870-672-0911
Practice Address - Fax:870-672-0914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-04
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care