Provider Demographics
NPI:1275692790
Name:ABRAHAM MEDICAL CENTER, PA
Entity Type:Organization
Organization Name:ABRAHAM MEDICAL CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:K SIMON
Authorized Official - Middle Name:S
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-425-6991
Mailing Address - Street 1:15 GREEN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-8102
Mailing Address - Country:US
Mailing Address - Phone:870-425-6991
Mailing Address - Fax:
Practice Address - Street 1:15 GREEN VALLEY DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-8102
Practice Address - Country:US
Practice Address - Phone:870-425-6991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101015002Medicaid
AR101015002Medicaid