Provider Demographics
NPI:1013930320
Name:ARKANSAS DERMATOLOGY PLLC
Entity Type:Organization
Organization Name:ARKANSAS DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEMMERLY
Authorized Official - Middle Name:DRAKE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-515-8136
Mailing Address - Street 1:4261 STOCKTON DRIVE SUITE LL100
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72117
Mailing Address - Country:US
Mailing Address - Phone:501-975-7456
Mailing Address - Fax:501-978-1822
Practice Address - Street 1:9601 BAPTIST HEALTH DR STE 860
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6375
Practice Address - Country:US
Practice Address - Phone:501-975-7455
Practice Address - Fax:501-975-3631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR155107002Medicaid
AR155107002Medicaid