Basic Information
| Provider Information | |||||||||
| NPI: | 1013930320 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARKANSAS DERMATOLOGY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4261 STOCKTON DRIVE SUITE LL100 | ||||||||
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| City: | NORTH LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019757456 | ||||||||
| FaxNumber: | 5019781822 | ||||||||
| Practice Location | |||||||||
| Address1: | 9601 BAPTIST HEALTH DR STE 860 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019757455 | ||||||||
| FaxNumber: | 5019753631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | HUMPHREYS | ||||||||
| AuthorizedOfficialFirstName: | KEMMERLY | ||||||||
| AuthorizedOfficialMiddleName: | DRAKE | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5015158136 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 155107002 | 05 | AR | MEDICAID |