Provider Demographics
NPI:1578045803
Name:BLUETAIL ARKANSAS PLLC
Entity Type:Organization
Organization Name:BLUETAIL ARKANSAS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-778-2900
Mailing Address - Street 1:C/O BLUETAIL MEDICAL GROUP, LLC
Mailing Address - Street 2:17300 NORTH OUTER 40 RD, STE 201
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1364
Mailing Address - Country:US
Mailing Address - Phone:636-778-2900
Mailing Address - Fax:636-778-2828
Practice Address - Street 1:9101 KANIS RD STE 200
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6455
Practice Address - Country:US
Practice Address - Phone:636-778-2900
Practice Address - Fax:636-778-2828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-04
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty