Provider Demographics
NPI:1164449500
Name:ARKANSAS OTOLARYNGOLOGY CENTER, P.A.
Entity Type:Organization
Organization Name:ARKANSAS OTOLARYNGOLOGY CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-227-5050
Mailing Address - Street 1:10201 KANIS RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6203
Mailing Address - Country:US
Mailing Address - Phone:501-227-5050
Mailing Address - Fax:501-227-5151
Practice Address - Street 1:10201 KANIS RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6203
Practice Address - Country:US
Practice Address - Phone:501-227-5050
Practice Address - Fax:501-227-5151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC0139207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104327002Medicaid
AR56691Medicare PIN
AR0820200001Medicare NSC