Provider Demographics
NPI:1528017761
Name:ADULT MEDICINE CLINIC OF BLYTHEVILLE, P.C.
Entity Type:Organization
Organization Name:ADULT MEDICINE CLINIC OF BLYTHEVILLE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHALENDER
Authorized Official - Middle Name:
Authorized Official - Last Name:MITTAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-762-5800
Mailing Address - Street 1:PO BOX 405
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72316-0405
Mailing Address - Country:US
Mailing Address - Phone:870-762-5800
Mailing Address - Fax:870-762-5801
Practice Address - Street 1:519 N 6TH ST
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-2407
Practice Address - Country:US
Practice Address - Phone:870-762-5800
Practice Address - Fax:870-762-5801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-06
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2710207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161250002Medicaid
AR141358001Medicaid
ARP00326909OtherRAILROAD MEDICARE
AR19103000000OtherQUALCHOICE
AR9360340OtherPHCS
ARDE9450OtherRAILROAD MEDICARE
AR9360340OtherPHCS
AR161250002Medicaid
ARP00326909OtherRAILROAD MEDICARE