Provider Demographics
NPI:1669466777
Name:SOUTH ARKANSAS NEPHROLOGY AND HYPERTENSION CLINIC
Entity Type:Organization
Organization Name:SOUTH ARKANSAS NEPHROLOGY AND HYPERTENSION CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KHALID
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHMOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-536-1400
Mailing Address - Street 1:2302 W 28TH AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-5050
Mailing Address - Country:US
Mailing Address - Phone:870-536-1400
Mailing Address - Fax:870-536-5196
Practice Address - Street 1:2302 W 28TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-5050
Practice Address - Country:US
Practice Address - Phone:870-536-1400
Practice Address - Fax:870-536-5196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0300207RN0300X
ARE3969207RN0300X
ARE40182084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Not Answered2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C052Medicare ID - Type Unspecified