Provider Demographics
NPI:1609181783
Name:DE QUEEN MEDICAL CENTER INC
Entity Type:Organization
Organization Name:DE QUEEN MEDICAL CENTER INC
Other - Org Name:DE QUEEN MEDICAL CENTER HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:CAPSHEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-584-4111
Mailing Address - Street 1:1306 W COLLIN RAYE DR
Mailing Address - Street 2:
Mailing Address - City:DE QUEEN
Mailing Address - State:AR
Mailing Address - Zip Code:71832-2502
Mailing Address - Country:US
Mailing Address - Phone:870-584-4111
Mailing Address - Fax:870-584-4100
Practice Address - Street 1:1007 N 14TH ST
Practice Address - Street 2:
Practice Address - City:DE QUEEN
Practice Address - State:AR
Practice Address - Zip Code:71832
Practice Address - Country:US
Practice Address - Phone:870-584-0277
Practice Address - Fax:870-584-0278
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DE QUEEN MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-12
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR5043251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR191767514Medicaid
AR191767514Medicaid
AR047177Medicare PIN
AR1184612194OtherBCBS OF AR