Provider Demographics
NPI:1134404130
Name:ARKANSAS RENAL GROUP PA
Entity type:Organization
Organization Name:ARKANSAS RENAL GROUP PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:P
Authorized Official - Last Name:EDGIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:501-624-6000
Mailing Address - Street 1:115 WRIGHTS ST
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-6240
Mailing Address - Country:US
Mailing Address - Phone:501-624-6000
Mailing Address - Fax:
Practice Address - Street 1:620 W GROVE ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4462
Practice Address - Country:US
Practice Address - Phone:870-862-0801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-21
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR190999002Medicaid
AR5GA19Medicare PIN