Provider Demographics
NPI:1205266632
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:
Authorized Official - Last Name:EDGIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-624-6000
Mailing Address - Street 1:115 WRIGHTS ST
Mailing Address - Street 2:SUITE C
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:501-321-0710
Practice Address - Street 1:115 WRIGHTS ST
Practice Address - Street 2:SUITE B
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6240
Practice Address - Country:US
Practice Address - Phone:501-624-6000
Practice Address - Fax:501-321-0710
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARKANSAS RENAL GROUP PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-21
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR207RN0300X, 261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR429616Medicare UPIN