Provider Demographics
NPI:1922769322
Name:ARKANSAS RENAL GROUP PA
Entity Type:Organization
Organization Name:ARKANSAS RENAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:EDGIN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:501-624-6000
Mailing Address - Street 1:115 WRIGHTS ST STE C
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-6240
Mailing Address - Country:US
Mailing Address - Phone:501-624-6000
Mailing Address - Fax:501-321-0710
Practice Address - Street 1:111 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3363
Practice Address - Country:US
Practice Address - Phone:501-624-6000
Practice Address - Fax:501-321-0710
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARKANSAS RENAL GROU PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty