Provider Demographics
NPI:1306826029
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:DALLAS COUNTY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR / 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 NORTH CLIFTON STREET
Mailing Address - Street 2:
Mailing Address - City:FORDYCE
Mailing Address - State:AR
Mailing Address - Zip Code:71742
Mailing Address - Country:US
Mailing Address - Phone:870-352-6363
Mailing Address - Fax:870-352-6343
Practice Address - Street 1:201 NORTH CLIFTON STREET
Practice Address - Street 2:
Practice Address - City:FORDYCE
Practice Address - State:AR
Practice Address - Zip Code:71742
Practice Address - Country:US
Practice Address - Phone:870-352-6363
Practice Address - Fax:870-352-6343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282NC0060X
ARAR4114282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR148217105Medicaid
AR11317OtherBCBS
041317Medicare Oscar/Certification
AR148217105Medicaid