Basic Information
Provider Information | |||||||||
NPI: | 1134295496 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KIDS FIRST MTN VIEW | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2009 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | MOUNTAIN VIEW | ||||||||
State: | AR | ||||||||
PostalCode: | 725606173 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016868000 | ||||||||
FaxNumber: | 5015266562 | ||||||||
Practice Location | |||||||||
Address1: | 2009 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | MOUNTAIN VIEW | ||||||||
State: | AR | ||||||||
PostalCode: | 72560 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016868000 | ||||||||
FaxNumber: | 5015266562 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/28/2006 | ||||||||
LastUpdateDate: | 06/08/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GEORGE | ||||||||
AuthorizedOfficialFirstName: | AMANDA | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | ASSOCIATE VC FOR CLINICAL FINANCE | ||||||||
AuthorizedOfficialTelephone: | 5016866633 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0006X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics |
ID Information
ID | Type | State | Issuer | Description | 136318724 | 05 | AR |   | MEDICAID |