Provider Demographics
NPI:1356317440
Name:SOUTH ARK EAR NOSE &THROAT CLINIC P A
Entity Type:Organization
Organization Name:SOUTH ARK EAR NOSE &THROAT CLINIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:SHORTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-535-5719
Mailing Address - Street 1:1722 W 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-7008
Mailing Address - Country:US
Mailing Address - Phone:870-535-5719
Mailing Address - Fax:870-536-1963
Practice Address - Street 1:1722 W 42ND AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-7008
Practice Address - Country:US
Practice Address - Phone:870-535-5719
Practice Address - Fax:870-536-1963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC1312207K00000X, 207KA0200X, 207Y00000X
ARA#283231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR142932720Medicaid
AR56924OtherARKANSAS BLUE CROSS BLUE SHIELD
AR103005702Medicaid
AR103005702Medicaid