Provider Demographics
NPI:1326781816
Name:POCAHONTAS MEDICAL CLINIC PA
Entity Type:Organization
Organization Name:POCAHONTAS MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARKUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-892-4467
Mailing Address - Street 1:2901 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:POCAHONTAS
Mailing Address - State:AR
Mailing Address - Zip Code:72455-9438
Mailing Address - Country:US
Mailing Address - Phone:870-892-4467
Mailing Address - Fax:870-892-4407
Practice Address - Street 1:400 W 4TH ST
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:AR
Practice Address - Zip Code:72422-2724
Practice Address - Country:US
Practice Address - Phone:870-892-4467
Practice Address - Fax:870-892-4407
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POCAHONTAS MEDICAL CLINIC, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR139208002Medicaid