Provider Demographics
NPI:1417110230
Name:UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
Entity Type:Organization
Organization Name:UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
Other - Org Name:AHEC FAYETTEVILLE PEDIATRIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:B J
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-521-8269
Mailing Address - Street 1:1125 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-1908
Mailing Address - Country:US
Mailing Address - Phone:479-521-8269
Mailing Address - Fax:479-443-3903
Practice Address - Street 1:1125 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1908
Practice Address - Country:US
Practice Address - Phone:479-521-8269
Practice Address - Fax:479-443-3903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR56997OtherAR BCBS
AR770033568OtherAR BREAST CARE
AR170583069Medicaid
AR56997OtherAR BCBS