Provider Demographics
NPI:1093084808
Name:CROSSETT HEALTH FOUNDATION
Entity Type:Organization
Organization Name:CROSSETT HEALTH FOUNDATION
Other - Org Name:HAMBURG HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:K
Authorized Official - Last Name:GILMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-364-1271
Mailing Address - Street 1:319 W PARKER ST
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:AR
Mailing Address - Zip Code:71646-3121
Mailing Address - Country:US
Mailing Address - Phone:870-853-8271
Mailing Address - Fax:870-364-1245
Practice Address - Street 1:319 W PARKER ST
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:AR
Practice Address - Zip Code:71646-3121
Practice Address - Country:US
Practice Address - Phone:870-853-8271
Practice Address - Fax:870-364-1245
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROSSETT HEALTH FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-22
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR54255OtherBLUE CROSS
AR163845729Medicaid
AR163845729Medicaid