Provider Demographics
NPI:1205895232
Name:CENTRAL MEDICAL GROUP
Entity type:Organization
Organization Name:CENTRAL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-664-5932
Mailing Address - Street 1:1 SAINT VINCENT CIR
Mailing Address - Street 2:SUITE 350
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5405
Mailing Address - Country:US
Mailing Address - Phone:501-664-5932
Mailing Address - Fax:501-296-9008
Practice Address - Street 1:1 SAINT VINCENT CIR
Practice Address - Street 2:SUITE 350
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5405
Practice Address - Country:US
Practice Address - Phone:501-664-5932
Practice Address - Fax:501-296-9008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-20
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4841207R00000X
ARC6406207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARC83684Medicare UPIN
ARD84232Medicare UPIN
AR57220Medicare ID - Type Unspecified