Provider Demographics
NPI:1336184431
Name:UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
Entity type:Organization
Organization Name:UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WYLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-541-6008
Mailing Address - Street 1:4010 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603
Mailing Address - Country:US
Mailing Address - Phone:870-541-6008
Mailing Address - Fax:870-541-6034
Practice Address - Street 1:203 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:STAR CITY
Practice Address - State:AR
Practice Address - Zip Code:71667
Practice Address - Country:US
Practice Address - Phone:870-628-5110
Practice Address - Fax:870-628-5949
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-20
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR112297003Medicaid
5F818Medicare PIN