Provider Demographics
NPI:1710291752
Name:TWIN LAKES PHYSICIAN GROUP PA
Entity Type:Organization
Organization Name:TWIN LAKES PHYSICIAN GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDVOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-425-6212
Mailing Address - Street 1:17 MEDICAL PLAZA
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653
Mailing Address - Country:US
Mailing Address - Phone:870-425-6212
Mailing Address - Fax:870-508-6896
Practice Address - Street 1:17 MEDICAL PLAZA
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653
Practice Address - Country:US
Practice Address - Phone:870-425-6212
Practice Address - Fax:870-508-6896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-02
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR184075002Medicaid
AR5G314OtherAR BC/BS
ARDQ7170OtherRAILROAD MEDICARE
AR5G314OtherAR BC/BS