Provider Demographics
NPI:1992083588
Name:MOUNTAIN HOME NEPHROLOGY AND PULMONOLOGY CLINIC
Entity type:Organization
Organization Name:MOUNTAIN HOME NEPHROLOGY AND PULMONOLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SARA
Authorized Official - Middle Name:REBECCA
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-786-0802
Mailing Address - Street 1:555 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-3409
Mailing Address - Country:US
Mailing Address - Phone:870-425-1787
Mailing Address - Fax:870-425-2009
Practice Address - Street 1:555 W 6TH ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3409
Practice Address - Country:US
Practice Address - Phone:870-425-1787
Practice Address - Fax:870-425-2009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-29
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-5121207RC0200X, 207RP1001X
ARE-5332207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty