Provider Demographics
NPI:1487841946
Name:MARKET PLACE MEDICAL CLINIC
Entity Type:Organization
Organization Name:MARKET PLACE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:L
Authorized Official - Last Name:CRANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-224-0794
Mailing Address - Street 1:11400 HURON LN
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-1847
Mailing Address - Country:US
Mailing Address - Phone:501-224-0794
Mailing Address - Fax:501-224-2838
Practice Address - Street 1:11400 HURON LN
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-1847
Practice Address - Country:US
Practice Address - Phone:501-224-0794
Practice Address - Fax:501-224-2838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC1256261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR57322Medicare PIN