Provider Demographics
NPI:1578591129
Name:SALEM FAMILY PRACTICE CLINIC,PA
Entity Type:Organization
Organization Name:SALEM FAMILY PRACTICE CLINIC,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCGARRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-794-4110
Mailing Address - Street 1:6640 CONGO RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019-6913
Mailing Address - Country:US
Mailing Address - Phone:501-794-4110
Mailing Address - Fax:501-316-9360
Practice Address - Street 1:6640 CONGO RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72019-6913
Practice Address - Country:US
Practice Address - Phone:501-794-4110
Practice Address - Fax:501-316-9360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC1718261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F075OtherBCBS
AR5F075OtherMEDICARE GROUP PTAN
AR5F075OtherBCBS