Provider Demographics
NPI:1982631347
Name:NORTHWEST ARKANSAS NEUROSURGERY CLINIC, PA
Entity Type:Organization
Organization Name:NORTHWEST ARKANSAS NEUROSURGERY CLINIC, PA
Other - Org Name:TOTAL SPINE
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:G
Authorized Official - Last Name:MATHIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-521-0900
Mailing Address - Street 1:5501 WILLOW CREEK DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-8704
Mailing Address - Country:US
Mailing Address - Phone:479-521-0900
Mailing Address - Fax:479-521-7284
Practice Address - Street 1:5501 WILLOW CREEK DR
Practice Address - Street 2:SUITE 203
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-8704
Practice Address - Country:US
Practice Address - Phone:479-521-0900
Practice Address - Fax:479-521-7284
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST ARKANSAS NEUROSURGERY CLINIC, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-28
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C180OtherBLUE CROSS/ BLUE SHIELD
AR5C180OtherBLUE CROSS/ BLUE SHIELD
AR5C180OtherBLUE CROSS/ BLUE SHIELD