Provider Demographics
NPI:1275618134
Name:ARKANSAS VALLEY UROLOGY CLINIC
Entity Type:Organization
Organization Name:ARKANSAS VALLEY UROLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/UROLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:HUGH
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-968-8765
Mailing Address - Street 1:2501 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:RUSSEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801
Mailing Address - Country:US
Mailing Address - Phone:479-968-8765
Mailing Address - Fax:479-967-6501
Practice Address - Street 1:2501 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:RUSSEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801
Practice Address - Country:US
Practice Address - Phone:479-968-8765
Practice Address - Fax:479-967-6501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4182208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D84090Medicare UPIN
AR50691Medicare ID - Type Unspecified