Provider Demographics
NPI:1609814185
Name:AMERIS OF ARKANSAS
Entity Type:Organization
Organization Name:AMERIS OF ARKANSAS
Other - Org Name:AMERIS
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENIS
Authorized Official - Middle Name:WELLINGTON
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-762-1190
Mailing Address - Street 1:1520 N DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-1448
Mailing Address - Country:US
Mailing Address - Phone:870-762-6725
Mailing Address - Fax:870-762-8125
Practice Address - Street 1:1100 MEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315
Practice Address - Country:US
Practice Address - Phone:870-762-6725
Practice Address - Fax:870-762-8125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK=========OtherTAX ID
ARY45036Medicare UPIN