Provider Demographics
NPI:1275708885
Name:BOARD OF GOVERNORS OF DALLAS COUNTY MEDICAL CENTER
Entity Type:Organization
Organization Name:BOARD OF GOVERNORS OF DALLAS COUNTY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION / CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-352-6363
Mailing Address - Street 1:201 N CLIFTON ST
Mailing Address - Street 2:
Mailing Address - City:FORDYCE
Mailing Address - State:AR
Mailing Address - Zip Code:71742-3026
Mailing Address - Country:US
Mailing Address - Phone:870-352-6363
Mailing Address - Fax:
Practice Address - Street 1:201 N CLIFTON ST
Practice Address - Street 2:
Practice Address - City:FORDYCE
Practice Address - State:AR
Practice Address - Zip Code:71742-3026
Practice Address - Country:US
Practice Address - Phone:870-352-6363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1Z317OtherBLUE CROSS BLUE SHIELD
AR04Z317Medicare Oscar/Certification