Provider Demographics
NPI:1598876278
Name:NORTHWEST ARKANSAS RENAL DIALYSIS ASSOCIATES
Entity Type:Organization
Organization Name:NORTHWEST ARKANSAS RENAL DIALYSIS ASSOCIATES
Other - Org Name:REGIONAL KIDNEY CENTER SILOAM SPRINGS DIALYSIS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:SMARDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-443-6688
Mailing Address - Street 1:509 E MILLSAP RD
Mailing Address - Street 2:SUITE111
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4067
Mailing Address - Country:US
Mailing Address - Phone:479-443-6688
Mailing Address - Fax:479-527-9917
Practice Address - Street 1:500 S MOUNT OLIVE ST
Practice Address - Street 2:SUITE 107
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-3602
Practice Address - Country:US
Practice Address - Phone:479-524-0104
Practice Address - Fax:479-524-0769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2362207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR12549OtherBCBS
AR042549Medicare Oscar/Certification
ARG28542Medicare UPIN