Provider Demographics
NPI:1184632705
Name:BARDELL, CRAIG R (MD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:R
Last Name:BARDELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 869
Mailing Address - Street 2:
Mailing Address - City:FORREST CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72336-0869
Mailing Address - Country:US
Mailing Address - Phone:570-640-4630
Mailing Address - Fax:
Practice Address - Street 1:1509 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-2067
Practice Address - Country:US
Practice Address - Phone:570-640-4630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3993207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR158899001Medicaid
AR5N446Medicare ID - Type Unspecified
ARE52825Medicare UPIN
AR57297Medicare PIN