1326019506 NPI number — UROLOGY GROUP OF WESTERN ARKANSAS

Table of content: (NPI 1326019506)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326019506 NPI number — UROLOGY GROUP OF WESTERN ARKANSAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UROLOGY GROUP OF WESTERN ARKANSAS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326019506
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 758
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72902-0758
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-709-7416
Provider Business Mailing Address Fax Number:
479-709-7417

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5500 ELLSWORTH RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SMITH
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72903-3222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-242-2411
Provider Business Practice Location Address Fax Number:
479-242-2412
Provider Enumeration Date:
01/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LANGE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
479-709-7416

Provider Taxonomy Codes

  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 154225002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5F080 . This is a "BLUE CROSS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 200027500A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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