Provider Demographics
NPI:1437125366
Name:MEDICAL CENTER CLINIC OF IZARD COUNTY LLC
Entity Type:Organization
Organization Name:MEDICAL CENTER CLINIC OF IZARD COUNTY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF STAFF
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:O
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-297-2475
Mailing Address - Street 1:PO BOX 819
Mailing Address - Street 2:
Mailing Address - City:CALICO ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72519-0819
Mailing Address - Country:US
Mailing Address - Phone:870-297-2475
Mailing Address - Fax:870-297-4380
Practice Address - Street 1:35 GRASSE STREET
Practice Address - Street 2:
Practice Address - City:CALICO ROCK
Practice Address - State:AR
Practice Address - Zip Code:72519
Practice Address - Country:US
Practice Address - Phone:870-297-2475
Practice Address - Fax:870-297-4380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR137324002Medicaid
5C216OtherBLUE CROSS BLUE SHIELD
93492OtherHEALTH PARTNERS
CG0617Medicare PIN
5C216OtherBLUE CROSS BLUE SHIELD