Provider Demographics
NPI:1336122340
Name:OTTER CREEK FAMILY CLINIC PLLC
Entity type:Organization
Organization Name:OTTER CREEK FAMILY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:RITA
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-455-1331
Mailing Address - Street 1:11321 INTERSTATE 30
Mailing Address - Street 2:STE 101
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72209-7059
Mailing Address - Country:US
Mailing Address - Phone:501-455-1331
Mailing Address - Fax:501-455-5597
Practice Address - Street 1:11321 INTERSTATE 30
Practice Address - Street 2:STE 101
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-7059
Practice Address - Country:US
Practice Address - Phone:501-455-1331
Practice Address - Fax:501-455-5597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC5502207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR140671002Medicaid
CG8625OtherRR MEDICARE
AR140671002Medicaid
CG8625OtherRR MEDICARE