Provider Demographics
NPI:1700842994
Name:CRITTENDEN HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:CRITTENDEN HOSPITAL ASSOCIATION
Other - Org Name:MID-SOUTH MULTI SPECIALTY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-735-1500
Mailing Address - Street 1:228 W TYLER AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-4223
Mailing Address - Country:US
Mailing Address - Phone:870-735-4025
Mailing Address - Fax:870-735-0570
Practice Address - Street 1:228 W TYLER AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4223
Practice Address - Country:US
Practice Address - Phone:870-735-4025
Practice Address - Fax:870-735-0570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN8431174400000X
207RI0200X, 207RP1001X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F794OtherBLUE CROSS GROUP
AR166512002Medicaid
AR5F794OtherBLUE CROSS GROUP