Provider Demographics
NPI:1013905587
Name:OZARK SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:OZARK SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-521-1484
Mailing Address - Street 1:3017 N BOB YOUNKIN DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3926
Mailing Address - Country:US
Mailing Address - Phone:479-521-1484
Mailing Address - Fax:479-521-1550
Practice Address - Street 1:3017 N BOB YOUNKIN DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3926
Practice Address - Country:US
Practice Address - Phone:479-521-1484
Practice Address - Fax:479-521-1550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7126208600000X
ARE0751208600000X
ARE3076208600000X
ARN8290208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146704002Medicaid
ARG88307Medicare UPIN
ARG06299Medicare UPIN
AR146704002Medicaid
ARH58537Medicare UPIN
ARC68038Medicare UPIN