Provider Demographics
NPI:1538279385
Name:COLLUM, G R (MD)
Entity Type:Individual
Prefix:
First Name:G
Middle Name:R
Last Name:COLLUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:HUGHES
Mailing Address - State:AR
Mailing Address - Zip Code:72348-9701
Mailing Address - Country:US
Mailing Address - Phone:870-339-3500
Mailing Address - Fax:870-339-3501
Practice Address - Street 1:503 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HUGHES
Practice Address - State:AR
Practice Address - Zip Code:72348-9701
Practice Address - Country:US
Practice Address - Phone:870-339-3500
Practice Address - Fax:870-339-3501
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4020208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR51142Medicare PIN