Provider Demographics
NPI:1235300765
Name:NORTHEAST ARKANSAS PAIN MEDICINE
Entity Type:Organization
Organization Name:NORTHEAST ARKANSAS PAIN MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:R
Authorized Official - Last Name:FORMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-972-0411
Mailing Address - Street 1:505 E MATTHEWS AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3144
Mailing Address - Country:US
Mailing Address - Phone:870-972-0411
Mailing Address - Fax:870-933-8011
Practice Address - Street 1:505 E MATTHEWS AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3144
Practice Address - Country:US
Practice Address - Phone:870-972-0411
Practice Address - Fax:870-933-8011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1479208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR143853002Medicaid
AR5K398OtherBLUE CROSS
AR5K398OtherBLUE CROSS