Provider Demographics
NPI:1255371753
Name:FAMILY MEDICAL CARE, PA
Entity type:Organization
Organization Name:FAMILY MEDICAL CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANVILLE
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:501-362-0048
Mailing Address - Street 1:PO BOX 1018
Mailing Address - Street 2:2225 HIGHWAY 110 WEST
Mailing Address - City:HEBER SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72543-1018
Mailing Address - Country:US
Mailing Address - Phone:501-362-0048
Mailing Address - Fax:501-362-8815
Practice Address - Street 1:2225 HIGHWAY 110 W
Practice Address - Street 2:
Practice Address - City:HEBER SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72543-3404
Practice Address - Country:US
Practice Address - Phone:501-362-0048
Practice Address - Fax:501-362-8815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7548207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149045002Medicaid
AR080191764OtherRAILROAD MEDICARE
AR149045002Medicaid
AR5C172Medicare PIN