Provider Demographics
NPI:1376820167
Name:OZARK FOOT & ANKLE PLC
Entity Type:Organization
Organization Name:OZARK FOOT & ANKLE PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:BRANTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:479-549-3835
Mailing Address - Street 1:PO BOX 8728
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-0013
Mailing Address - Country:US
Mailing Address - Phone:479-549-3835
Mailing Address - Fax:479-549-4146
Practice Address - Street 1:500 S MOUNT OLIVE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-3602
Practice Address - Country:US
Practice Address - Phone:479-549-3835
Practice Address - Fax:479-549-4146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR152213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR811005690OtherSECRETARY OF STATE- DEPT OF CORPORATIONS
5GA25Medicare PIN