Provider Demographics
NPI:1609837459
Name:ARKANSAS ALLERGY & ASTHMA CLINIC, P.A.
Entity Type:Organization
Organization Name:ARKANSAS ALLERGY & ASTHMA CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PRINCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-329-0237
Mailing Address - Street 1:400 SALEM RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-6162
Mailing Address - Country:US
Mailing Address - Phone:501-329-0237
Mailing Address - Fax:501-932-0565
Practice Address - Street 1:400 SALEM RD
Practice Address - Street 2:SUITE 4
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-6162
Practice Address - Country:US
Practice Address - Phone:501-329-0237
Practice Address - Fax:501-932-0565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104277002Medicaid
AR56681Medicare PIN