Basic Information
| Provider Information | |||||||||
| NPI: | 1114109147 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIRBY | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6210 BASELINE RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5014128861 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6210 BASELINE ROAD THE P.A.T. CENTER | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012650302 | ||||||||
| FaxNumber: | 5012650300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2007 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | AR | Y | Other Service Providers | Case Manager/Care Coordinator | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 160512526 | 05 | AR | MEDICAID |