Provider Demographics
NPI:1417009374
Name:CLARKSVILLE MEDICAL GROUP, P.A.
Entity Type:Organization
Organization Name:CLARKSVILLE MEDICAL GROUP, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEANNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:PERRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-754-8384
Mailing Address - Street 1:PO BOX 668
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-0668
Mailing Address - Country:US
Mailing Address - Phone:479-754-8384
Mailing Address - Fax:479-754-7141
Practice Address - Street 1:601 W MCKENNON ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-3523
Practice Address - Country:US
Practice Address - Phone:479-754-8384
Practice Address - Fax:479-754-7141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC0283291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory