Provider Demographics
NPI:1568529295
Name:ARKANSAS CENTER FOR ARTHROSCOPY, PA
Entity Type:Organization
Organization Name:ARKANSAS CENTER FOR ARTHROSCOPY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:P
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:479-273-1111
Mailing Address - Street 1:1504 SE 28TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-3988
Mailing Address - Country:US
Mailing Address - Phone:479-273-1111
Mailing Address - Fax:479-273-1255
Practice Address - Street 1:1504 SE 28TH ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3988
Practice Address - Country:US
Practice Address - Phone:479-273-1111
Practice Address - Fax:479-273-1255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1612771002Medicaid