Provider Demographics
NPI:1114906393
Name:PHYSICIANS SURGERY CENTER LLC
Entity Type:Organization
Organization Name:PHYSICIANS SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:H
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-762-1942
Mailing Address - Street 1:PO BOX 92
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72316-0092
Mailing Address - Country:US
Mailing Address - Phone:870-762-1942
Mailing Address - Fax:870-763-0787
Practice Address - Street 1:3327 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-5123
Practice Address - Country:US
Practice Address - Phone:870-762-1942
Practice Address - Fax:870-763-0787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-16
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR4222261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR154372128Medicaid
AR154372128Medicaid