Provider Demographics
NPI:1821131665
Name:FORT SMITH REGIONAL DIALYSIS, LLC
Entity Type:Organization
Organization Name:FORT SMITH REGIONAL DIALYSIS, LLC
Other - Org Name:STILWELL DIALYSIS
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-755-6700
Mailing Address - Street 1:2201 BROOKEN HILL DR
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72908-8611
Mailing Address - Country:US
Mailing Address - Phone:479-755-6700
Mailing Address - Fax:479-755-6704
Practice Address - Street 1:319 N 2ND ST
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960-2609
Practice Address - Country:US
Practice Address - Phone:479-755-6700
Practice Address - Fax:479-755-6704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK900522191Medicare ID - Type UnspecifiedSTILWELL DIALYSIS