Provider Demographics
NPI:1629027818
Name:AUTUMN ROAD FAMILY PRACTICE, P.A,
Entity Type:Organization
Organization Name:AUTUMN ROAD FAMILY PRACTICE, P.A,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:DRENNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-626-7515
Mailing Address - Street 1:904 AUTUMN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3737
Mailing Address - Country:US
Mailing Address - Phone:501-227-6363
Mailing Address - Fax:501-227-8629
Practice Address - Street 1:904 AUTUMN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3737
Practice Address - Country:US
Practice Address - Phone:501-227-6363
Practice Address - Fax:501-227-8629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC0079261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR111026102Medicaid
AR56813Medicare PIN