Provider Demographics
NPI:1144312299
Name:MORRILTON MEDICAL CLINIC, P.A.
Entity type:Organization
Organization Name:MORRILTON MEDICAL CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HOELZEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-354-0052
Mailing Address - Street 1:#10 HOSPITAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:MORRILTON
Mailing Address - State:AR
Mailing Address - Zip Code:72110
Mailing Address - Country:US
Mailing Address - Phone:501-354-0052
Mailing Address - Fax:501-354-9142
Practice Address - Street 1:#10 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:MORRILTON
Practice Address - State:AR
Practice Address - Zip Code:72110
Practice Address - Country:US
Practice Address - Phone:501-354-0052
Practice Address - Fax:501-354-9142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR113040002Medicaid
AR113040002Medicaid
AR0659750001Medicare NSC