Provider Demographics
NPI:1093060824
Name:PHYSICIAN GROUP OF ARKANSAS, INC.
Entity Type:Organization
Organization Name:PHYSICIAN GROUP OF ARKANSAS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEMKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-467-1072
Mailing Address - Street 1:PO BOX 842109
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-2109
Mailing Address - Country:US
Mailing Address - Phone:866-286-2802
Mailing Address - Fax:314-432-9683
Practice Address - Street 1:2001 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HOPE
Practice Address - State:AR
Practice Address - Zip Code:71801-8124
Practice Address - Country:US
Practice Address - Phone:870-777-2323
Practice Address - Fax:870-722-7158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-18
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR196268002Medicaid
AZ248550Medicare PIN