Provider Demographics
NPI:1275628596
Name:SAM SCROGGINS MD PA
Entity Type:Organization
Organization Name:SAM SCROGGINS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:I
Authorized Official - Last Name:SCROGGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-741-6373
Mailing Address - Street 1:1002 N SPRING ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601
Mailing Address - Country:US
Mailing Address - Phone:870-741-6373
Mailing Address - Fax:870-741-5102
Practice Address - Street 1:1002 N SPRING ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601
Practice Address - Country:US
Practice Address - Phone:870-741-6373
Practice Address - Fax:870-741-5102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4664207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110143007Medicaid
AR13888000000OtherQUALCHOICE
AR5B000OtherBLUE CROSS BLUE SHIELD
C68716Medicare UPIN
AR5B000OtherBLUE CROSS BLUE SHIELD