Provider Demographics
NPI:1770634065
Name:NORTHWEST ARKANSAS GASTROENTEROLOGY CLINIC PA
Entity Type:Organization
Organization Name:NORTHWEST ARKANSAS GASTROENTEROLOGY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LENEVA
Authorized Official - Middle Name:JENELL
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-770-2135
Mailing Address - Street 1:116 W MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-9682
Mailing Address - Country:US
Mailing Address - Phone:479-770-8090
Mailing Address - Fax:479-770-8062
Practice Address - Street 1:116 W MONROE AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:AR
Practice Address - Zip Code:72745-9682
Practice Address - Country:US
Practice Address - Phone:479-770-8090
Practice Address - Fax:479-770-8062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR57825Medicare ID - Type UnspecifiedMEDICARE NUMBER