Provider Demographics
NPI:1295030815
Name:URBAN MEDICAL CLINIC
Entity Type:Organization
Organization Name:URBAN MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-424-5079
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-0310
Mailing Address - Country:US
Mailing Address - Phone:870-424-5079
Mailing Address - Fax:870-424-8455
Practice Address - Street 1:1 WEST CHEROKEE VILLAGE MALL #12
Practice Address - Street 2:
Practice Address - City:CHEROKEE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:72529
Practice Address - Country:US
Practice Address - Phone:870-257-4110
Practice Address - Fax:870-257-4112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-12
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR3890208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty