Provider Demographics
NPI:1942243787
Name:REEL FAMILY FOOT CLINIC, P.A.
Entity Type:Organization
Organization Name:REEL FAMILY FOOT CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:CARROLL
Authorized Official - Last Name:REEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:479-880-2600
Mailing Address - Street 1:PO BOX 9178
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-9178
Mailing Address - Country:US
Mailing Address - Phone:479-968-4273
Mailing Address - Fax:479-968-1363
Practice Address - Street 1:201 E PARKWAY DR
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3913
Practice Address - Country:US
Practice Address - Phone:479-880-2600
Practice Address - Fax:479-880-8076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR215213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159972748Medicaid
AR5661560001Medicare NSC
AR5F801Medicare PIN