Provider Demographics
NPI:1659340297
Name:NE ARKANSAS OTOLARYNGOLOGY FACIAL SURGERY P A
Entity Type:Organization
Organization Name:NE ARKANSAS OTOLARYNGOLOGY FACIAL SURGERY P A
Other - Org Name:OTOLARYNGOLOGY AND FACIAL SURGERY CENTRE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-932-6799
Mailing Address - Street 1:621 E MATTHEWS AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3145
Mailing Address - Country:US
Mailing Address - Phone:870-932-6799
Mailing Address - Fax:870-932-8423
Practice Address - Street 1:621 E MATTHEWS AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3145
Practice Address - Country:US
Practice Address - Phone:870-932-6799
Practice Address - Fax:870-932-8423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR57432OtherBCBS OF AR PROVIDER NUMBE
AR101792002Medicaid
CK6516OtherRAILRAOD MEDICARE
AR57432Medicare PIN