Provider Demographics
NPI:1043692718
Name:RAYMED PA
Entity Type:Organization
Organization Name:RAYMED PA
Other - Org Name:WHITE HALL WALK IN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KONSTANTIN
Authorized Official - Middle Name:I
Authorized Official - Last Name:GUBRIJ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-410-3696
Mailing Address - Street 1:PO BOX 251753
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72225-1753
Mailing Address - Country:US
Mailing Address - Phone:501-410-3696
Mailing Address - Fax:
Practice Address - Street 1:7250 SHERIDAN ROAD
Practice Address - Street 2:
Practice Address - City:WHITE HALL
Practice Address - State:AR
Practice Address - Zip Code:71602-0000
Practice Address - Country:US
Practice Address - Phone:501-749-8892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE7850261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center