Provider Demographics
NPI:1427284694
Name:CONDREY PEDIATRIC CLINIC
Entity type:Organization
Organization Name:CONDREY PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-425-6272
Mailing Address - Street 1:4 MEDICAL PLZ
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-2919
Mailing Address - Country:US
Mailing Address - Phone:870-425-6272
Mailing Address - Fax:870-424-3320
Practice Address - Street 1:4 MEDICAL PLZ
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2919
Practice Address - Country:US
Practice Address - Phone:870-425-6272
Practice Address - Fax:870-424-3320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty