Provider Demographics
NPI:1699070649
Name:MERCY CLINIC FORT SMITH COMMUNITIES
Entity type:Organization
Organization Name:MERCY CLINIC FORT SMITH COMMUNITIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:COLE
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:479-314-6100
Mailing Address - Street 1:2901 S 74TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5156
Mailing Address - Country:US
Mailing Address - Phone:479-314-1101
Mailing Address - Fax:479-314-4704
Practice Address - Street 1:3501 WE KNIGHT DR
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-6248
Practice Address - Country:US
Practice Address - Phone:479-709-6700
Practice Address - Fax:479-790-6709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-24
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR186193002Medicaid
OK200199350HMedicaid
ARDR1533OtherRAILROAD MEDICARE
AR5G406OtherBLUE CROSS BLUE SHIELD
AR5G765Medicare PIN