Provider Demographics
NPI:1992992085
Name:NORTHEAST ARK INT MED C
Entity type:Organization
Organization Name:NORTHEAST ARK INT MED C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SERVICES COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:870-934-5117
Mailing Address - Street 1:1835 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401
Mailing Address - Country:US
Mailing Address - Phone:870-934-5117
Mailing Address - Fax:870-932-3191
Practice Address - Street 1:311 E MATTHEWS AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:870-935-4150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR18059Medicare PIN