Provider Demographics
NPI:1124216700
Name:SOUTHWEST ARKANSAS EAR, NOSE & THROAT CLINIC
Entity Type:Organization
Organization Name:SOUTHWEST ARKANSAS EAR, NOSE & THROAT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SKALESKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-722-6200
Mailing Address - Street 1:100 E 20TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:HOPE
Mailing Address - State:AR
Mailing Address - Zip Code:71801-8222
Mailing Address - Country:US
Mailing Address - Phone:870-722-6200
Mailing Address - Fax:870-722-2927
Practice Address - Street 1:100 E 20TH ST STE A
Practice Address - Street 2:
Practice Address - City:HOPE
Practice Address - State:AR
Practice Address - Zip Code:71801-8222
Practice Address - Country:US
Practice Address - Phone:870-722-6200
Practice Address - Fax:870-722-2927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2011-05-13
Deactivation Date:2010-07-27
Deactivation Code:
Reactivation Date:2011-05-13
Provider Licenses
StateLicense IDTaxonomies
ARR2502207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR55795OtherBLUE CROSS BLUE SHIELD
AR106113001Medicaid
AR55795Medicare PIN
ARD05019Medicare UPIN