Provider Demographics
NPI:1609847847
Name:SOUTH, BARRON TRACY (MS, PT)
Entity Type:Individual
Prefix:
First Name:BARRON
Middle Name:TRACY
Last Name:SOUTH
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 E DOUBLE EAGLE PL
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-7143
Mailing Address - Country:US
Mailing Address - Phone:479-856-6571
Mailing Address - Fax:479-856-6571
Practice Address - Street 1:505 E DOUBLE EAGLE PL
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-7143
Practice Address - Country:US
Practice Address - Phone:479-856-6571
Practice Address - Fax:479-856-6571
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC22172225000000X
ARPT 1781225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR129332721Medicaid