Provider Demographics
NPI:1013917905
Name:CROSS, AMY W (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:W
Last Name:CROSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 E MCNEIL
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-2927
Mailing Address - Country:US
Mailing Address - Phone:870-234-5171
Mailing Address - Fax:870-234-0507
Practice Address - Street 1:306 E MCNEIL
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-2927
Practice Address - Country:US
Practice Address - Phone:870-234-5171
Practice Address - Fax:870-234-0507
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2147208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR136968001Medicaid
AR5L245Medicare ID - Type Unspecified
AR136968001Medicaid