Basic Information
| Provider Information | |||||||||
| NPI: | 1952074916 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 102 TOWNE CENTRE DR STE 2 | ||||||||
| Address2: | |||||||||
| City: | MAUMELLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721137756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016868000 | ||||||||
| FaxNumber: | 5015265148 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 TOWNE CENTRE DR STE 2 | ||||||||
| Address2: | |||||||||
| City: | MAUMELLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721137756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016868000 | ||||||||
| FaxNumber: | 5015265148 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2021 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GEORGE | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE CHANCELLOR-CHIEF FINANCIAL OFF | ||||||||
| AuthorizedOfficialTelephone: | 5016865670 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF ARKANSAS MEDICAL SCIENCES | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.