Provider Demographics
NPI:1679764419
Name:SUPHAN MEDICAL CLINIC
Entity Type:Organization
Organization Name:SUPHAN MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:NEEMA
Authorized Official - Middle Name:G
Authorized Official - Last Name:SUPHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-225-7500
Mailing Address - Street 1:11811 HINSON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-3404
Mailing Address - Country:US
Mailing Address - Phone:501-225-7500
Mailing Address - Fax:501-225-7510
Practice Address - Street 1:11811 HINSON RD STE 200
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-3404
Practice Address - Country:US
Practice Address - Phone:501-225-7500
Practice Address - Fax:501-225-7510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR-2871207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR51832Medicare UPIN