1679577381 NPI number — KATHERINE A IRISH-CLARDY M.D.

Table of content: KATHERINE A IRISH-CLARDY M.D. (NPI 1679577381)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679577381 NPI number — KATHERINE A IRISH-CLARDY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IRISH-CLARDY
Provider First Name:
KATHERINE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1679577381
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
612 S 12TH ST
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:
72901-4702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-785-2431
Provider Business Mailing Address Fax Number:
479-494-7787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 S E ST
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:
72901-4716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-785-2431
Provider Business Practice Location Address Fax Number:
479-494-7787
Provider Enumeration Date:
06/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  E-2393 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7889253 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 143782001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2087945 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 5L856 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 08172336 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 19334000001 . This is a "QUALCHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 9642236001 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00127019 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100000610A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1646351 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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