Provider Demographics
NPI:1699736777
Name:EXECUTIVE PARK SURGERY CENTER, LLC
Entity type:Organization
Organization Name:EXECUTIVE PARK SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:M
Authorized Official - Last Name:ENNEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-424-2744
Mailing Address - Street 1:3314 S 70TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5052
Mailing Address - Country:US
Mailing Address - Phone:479-424-2744
Mailing Address - Fax:479-424-2745
Practice Address - Street 1:3314 S 70TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5052
Practice Address - Country:US
Practice Address - Phone:479-424-2744
Practice Address - Fax:479-424-2745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200041770AMedicaid
AR155824128Medicaid
AR155824128Medicaid