Provider Demographics
NPI:1821117565
Name:ARKANSAS INTERNAL MEDICINE CLINIC PA
Entity Type:Organization
Organization Name:ARKANSAS INTERNAL MEDICINE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SOLOMON
Authorized Official - Middle Name:CHUKWUEMEKA
Authorized Official - Last Name:MOGBO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-537-4590
Mailing Address - Street 1:500 S UNIVERSITY AVE STE 605
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5308
Mailing Address - Country:US
Mailing Address - Phone:501-537-4590
Mailing Address - Fax:
Practice Address - Street 1:500 S UNIVERSITY AVE STE 605
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5308
Practice Address - Country:US
Practice Address - Phone:501-537-4590
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AREI875174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145707001Medicaid
AR149931002Medicaid
AR=========OtherTAX ID
AR5L622Medicare ID - Type Unspecified
AR145707001Medicaid