Provider Demographics
NPI:1366943151
Name:ARKANSAS LIVER AND GASTROENTEROLOGY, PA
Entity type:Organization
Organization Name:ARKANSAS LIVER AND GASTROENTEROLOGY, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:JESSICA-ELISE
Authorized Official - Last Name:COLUCCINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-242-2888
Mailing Address - Street 1:3416 OLD GREENWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903
Mailing Address - Country:US
Mailing Address - Phone:479-242-2888
Mailing Address - Fax:479-242-2889
Practice Address - Street 1:2347 NORTH THOMPKINS AVE
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008
Practice Address - Country:US
Practice Address - Phone:479-242-2888
Practice Address - Fax:479-242-2889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR21089002Medicaid
OK2006036301AMedicaid