Provider Demographics
NPI:1700830718
Name:SALINE MEDICAL GROUP
Entity Type:Organization
Organization Name:SALINE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:L
Authorized Official - Last Name:TILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-315-4512
Mailing Address - Street 1:624 ALCOA
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-3404
Mailing Address - Country:US
Mailing Address - Phone:501-315-4512
Mailing Address - Fax:501-315-0917
Practice Address - Street 1:624 ALCOA
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3404
Practice Address - Country:US
Practice Address - Phone:501-315-4512
Practice Address - Fax:501-315-0917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK105459002Medicaid
56737Medicare ID - Type Unspecified