Provider Demographics
NPI:1851467831
Name:PHOENIX HEALTH ASSOCIATES OF FORT SMITH
Entity Type:Organization
Organization Name:PHOENIX HEALTH ASSOCIATES OF FORT SMITH
Other - Org Name:PHYSICIANS' DAY SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN, GOVERNING BODY
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOLYARD
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:479-709-7272
Mailing Address - Street 1:PO BOX 10626
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-0626
Mailing Address - Country:US
Mailing Address - Phone:479-709-7272
Mailing Address - Fax:
Practice Address - Street 1:3601 W E KNIGHT DRIVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903
Practice Address - Country:US
Practice Address - Phone:479-709-7272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR4378261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200107730AMedicaid
AR163231128Medicaid
AR163231128Medicaid
5951120001Medicare NSC