Provider Demographics
NPI:1861488587
Name:LITTLE ROCK OUTPATIENT SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:LITTLE ROCK OUTPATIENT SURGERY CENTER, LLC
Other - Org Name:RIVERCREST ANESTHESIA SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:KINCAID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-217-9007
Mailing Address - Street 1:8907 KANIS RD
Mailing Address - Street 2:STE. 100
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6449
Mailing Address - Country:US
Mailing Address - Phone:501-217-9007
Mailing Address - Fax:501-221-0337
Practice Address - Street 1:8907 KANIS RD
Practice Address - Street 2:STE. 100
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6449
Practice Address - Country:US
Practice Address - Phone:501-217-9007
Practice Address - Fax:501-221-0337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F321OtherBCBS
AR5F321Medicare PIN