Provider Demographics
NPI:1972613743
Name:MCCRORY FAMILY CLINIC PA
Entity type:Organization
Organization Name:MCCRORY FAMILY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-731-1100
Mailing Address - Street 1:PO BOX 780
Mailing Address - Street 2:
Mailing Address - City:MCCRORY
Mailing Address - State:AR
Mailing Address - Zip Code:72101
Mailing Address - Country:US
Mailing Address - Phone:870-731-1100
Mailing Address - Fax:870-731-1019
Practice Address - Street 1:908 N EDMONDS AVE
Practice Address - Street 2:
Practice Address - City:MCCRORY
Practice Address - State:AR
Practice Address - Zip Code:72101
Practice Address - Country:US
Practice Address - Phone:870-731-1100
Practice Address - Fax:870-731-1019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC-1803261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARCI5031OtherRAILROAD MEDICARE
AR134474729Medicaid
AR134056002Medicaid
AR134474729Medicaid
AR134056002Medicaid