Provider Demographics
NPI:1376939785
Name:UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCE SOUTH
Entity Type:Organization
Organization Name:UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCE SOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY MEDICINE RESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDILBERTO
Authorized Official - Middle Name:DIZON
Authorized Official - Last Name:ATIENZA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:240-462-7236
Mailing Address - Street 1:1725 ALLERFORD DR
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MD
Mailing Address - Zip Code:21076-1798
Mailing Address - Country:US
Mailing Address - Phone:240-462-7236
Mailing Address - Fax:
Practice Address - Street 1:1617 N WASHINGTON
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-2046
Practice Address - Country:US
Practice Address - Phone:240-462-7236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-13
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural