Provider Demographics
NPI:1962521617
Name:GARY L. POOLE
Entity type:Organization
Organization Name:GARY L. POOLE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:870-533-8808
Mailing Address - Street 1:218 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:STAMPS
Mailing Address - State:AR
Mailing Address - Zip Code:71860-2816
Mailing Address - Country:US
Mailing Address - Phone:870-533-8808
Mailing Address - Fax:870-533-8838
Practice Address - Street 1:218 CHURCH ST
Practice Address - Street 2:
Practice Address - City:STAMPS
Practice Address - State:AR
Practice Address - Zip Code:71860-2816
Practice Address - Country:US
Practice Address - Phone:870-533-8808
Practice Address - Fax:870-533-8838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAO1177363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150962762Medicaid
P00115264OtherRAILROAD MEDICARE
AR5J597OtherBCBS
1316914724OtherPROVIDER INDIVIDUAL NPI#
AR5C958OtherBLUE CROSS AND BLUE SHIEL
AR5U007Medicare ID - Type Unspecified
AR150962762Medicaid