Provider Demographics
NPI:1467586131
Name:GREAT RIVER PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:GREAT RIVER PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ASAFO-BOAKYE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH, FAAP
Authorized Official - Phone:870-780-6832
Mailing Address - Street 1:1521 N 10TH ST
Mailing Address - Street 2:STE F
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-1405
Mailing Address - Country:US
Mailing Address - Phone:870-780-6832
Mailing Address - Fax:870-780-6919
Practice Address - Street 1:1521 N 10TH ST
Practice Address - Street 2:STE F
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-1405
Practice Address - Country:US
Practice Address - Phone:870-780-6832
Practice Address - Fax:870-780-6919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4133208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F511OtherBLUE CROSS BLUE SHIELD
AR5F511OtherBLUE CROSS BLUE SHIELD