Provider Demographics
NPI:1689625659
Name:CROSSROADS MEDICAL CLINIC OF HARRISON
Entity Type:Organization
Organization Name:CROSSROADS MEDICAL CLINIC OF HARRISON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:CAUSEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-741-3600
Mailing Address - Street 1:PO BOX 9178
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-9178
Mailing Address - Country:US
Mailing Address - Phone:479-968-4273
Mailing Address - Fax:479-968-4331
Practice Address - Street 1:1420 HWY 62 65 N
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-1959
Practice Address - Country:US
Practice Address - Phone:870-741-3600
Practice Address - Fax:870-741-6800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR160850002Medicaid
AR160850002Medicaid