Provider Demographics
NPI:1003877853
Name:ARKANSAS ALLERGY & ASTHMA CLINIC, P.A.
Entity Type:Organization
Organization Name:ARKANSAS ALLERGY & ASTHMA CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-227-5210
Mailing Address - Street 1:PO BOX 55090
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72215-5090
Mailing Address - Country:US
Mailing Address - Phone:501-227-5210
Mailing Address - Fax:501-312-1592
Practice Address - Street 1:5 EXECUTIVE CENTER CT
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-4375
Practice Address - Country:US
Practice Address - Phone:501-227-5210
Practice Address - Fax:501-312-1592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104277002Medicaid
AR104277002Medicaid