Provider Demographics
NPI:1982193975
Name:MONTICELLO MEDICAL CLINIC, PLC
Entity Type:Organization
Organization Name:MONTICELLO MEDICAL CLINIC, PLC
Other - Org Name:MMC-STAR CITY SATELLITE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SYLVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-367-6867
Mailing Address - Street 1:906 ROBERTS DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-5724
Mailing Address - Country:US
Mailing Address - Phone:870-367-6867
Mailing Address - Fax:870-367-1461
Practice Address - Street 1:1306 N. LINCOLN AVENUE
Practice Address - Street 2:
Practice Address - City:STAR CITY
Practice Address - State:AR
Practice Address - Zip Code:71667
Practice Address - Country:US
Practice Address - Phone:870-628-1388
Practice Address - Fax:870-628-1347
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONTICELLO MEDICAL CLINIC PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC-1891207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR139812002Medicaid