Basic Information
| Provider Information | |||||||||
| NPI: | 1215915459 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. ANTHONY'S HOSPITAL ASSOCIATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ST. VINCENT MEDICAL CLINIC MORRILTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | MORRILTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721104510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013544637 | ||||||||
| FaxNumber: | 5013542248 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | MORRILTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721104510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013544637 | ||||||||
| FaxNumber: | 5013542248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 11/29/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOGAN | ||||||||
| AuthorizedOfficialFirstName: | TIFFANY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5013544637 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | C5434 | AR | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RC0000X | N5860 | AR | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 363LF0000X | A01404 | AR | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QR1300X | AR | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 134783729 | 05 | AR | MEDICAID |