Provider Demographics
NPI:1710229059
Name:PADLEY, REBECCA MARIE (MD, MBA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARIE
Last Name:PADLEY
Suffix:
Gender:F
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-4702
Mailing Address - Country:US
Mailing Address - Phone:913-636-0557
Mailing Address - Fax:
Practice Address - Street 1:612 S 12TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4702
Practice Address - Country:US
Practice Address - Phone:479-424-3193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-9587207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR507805YNV7Medicare PIN
AR507805YNWEMedicare PIN