Provider Demographics
NPI:1538486113
Name:EMERGENCY MEDICINE OF NORTHWEST ARKANSAS, LLC
Entity Type:Organization
Organization Name:EMERGENCY MEDICINE OF NORTHWEST ARKANSAS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:M
Authorized Official - Last Name:AUDIBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-633-4102
Mailing Address - Street 1:3873 NORTH PARKVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703
Mailing Address - Country:US
Mailing Address - Phone:479-466-0432
Mailing Address - Fax:
Practice Address - Street 1:3873 NORTH PARKVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-466-0432
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-22
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR207P00000X
207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR183700002Medicaid
AR5G278OtherARKANSAS BLUE CROSS
AR5G525Medicare PIN