Provider Demographics
NPI:1144561390
Name:MODERN MEDICINE PLLC
Entity Type:Organization
Organization Name:MODERN MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LONNIE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-826-7500
Mailing Address - Street 1:350 E MILLSAP RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4098
Mailing Address - Country:US
Mailing Address - Phone:479-439-8020
Mailing Address - Fax:479-439-8022
Practice Address - Street 1:350 E MILLSAP RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4098
Practice Address - Country:US
Practice Address - Phone:479-439-8020
Practice Address - Fax:479-439-8022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-13
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1887208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty