Provider Demographics
NPI:1811020118
Name:PAUL J BAXLEY, M.D., P.A.
Entity Type:Organization
Organization Name:PAUL J BAXLEY, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:KRTICKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-315-4008
Mailing Address - Street 1:1000 HIGHWAY 35 N STE 8
Mailing Address - Street 2:P. O. BOX 2860
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019-2353
Mailing Address - Country:US
Mailing Address - Phone:501-315-4008
Mailing Address - Fax:501-315-3411
Practice Address - Street 1:1000 HIGHWAY 35 N STE 8
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72019-2353
Practice Address - Country:US
Practice Address - Phone:501-315-4008
Practice Address - Fax:501-315-3411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4798174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104490001Medicaid
AR5G997OtherMEDICARE-GROUP
AR1164414462OtherINDIV-NPI #
AR104490001Medicaid
AR1164414462OtherINDIV-NPI #