Provider Demographics
NPI:1346519428
Name:SHORT, EDWARD CLARK (PT)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:CLARK
Last Name:SHORT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 W MAIN ST
Mailing Address - Street 2:RUSSELLVILLE
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2453
Mailing Address - Country:US
Mailing Address - Phone:479-967-9657
Mailing Address - Fax:479-967-9658
Practice Address - Street 1:3016 W MAIN ST
Practice Address - Street 2:RUSSELLVILLE
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2453
Practice Address - Country:US
Practice Address - Phone:479-967-9657
Practice Address - Fax:479-967-9658
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-20
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2693225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist