Provider Demographics
NPI:1376558023
Name:MIDSTATE MED-CARE, INC.
Entity Type:Organization
Organization Name:MIDSTATE MED-CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MGR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-932-0033
Mailing Address - Street 1:PO BOX 781
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72033-0781
Mailing Address - Country:US
Mailing Address - Phone:501-932-3180
Mailing Address - Fax:501-932-0261
Practice Address - Street 1:800 EXCHANGE AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-7833
Practice Address - Country:US
Practice Address - Phone:501-932-3180
Practice Address - Fax:501-932-0261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR124637716332B00000X, 332BN1400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR124637716Medicaid
AR124637716Medicaid