Provider Demographics
NPI:1831130616
Name:FAMILY MEDICINE ASSOCIATES OF PINE
Entity Type:Organization
Organization Name:FAMILY MEDICINE ASSOCIATES OF PINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:FRAZIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-541-9373
Mailing Address - Street 1:1801 W 40TH AVE
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6900
Mailing Address - Country:US
Mailing Address - Phone:870-541-9373
Mailing Address - Fax:870-541-0109
Practice Address - Street 1:1801 W 40TH AVE
Practice Address - Street 2:SUITE 6A
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6900
Practice Address - Country:US
Practice Address - Phone:870-541-9373
Practice Address - Fax:870-541-0109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR57007Medicare ID - Type Unspecified