Provider Demographics
NPI:1982661500
Name:CRITTENDEN HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:CRITTENDEN HOSPITAL ASSOCIATION
Other - Org Name:MID-SOUTH PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:PRINCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-735-1500
Mailing Address - Street 1:2921 HWY 77
Mailing Address - Street 2:SUITE 20
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-2367
Mailing Address - Country:US
Mailing Address - Phone:870-739-5311
Mailing Address - Fax:870-739-5542
Practice Address - Street 1:2921 HWY 77
Practice Address - Street 2:SUITE 20
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-2367
Practice Address - Country:US
Practice Address - Phone:870-739-5311
Practice Address - Fax:870-739-5542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR133764002Medicaid