Provider Demographics
NPI:1295166676
Name:E.P. CORTEZ MEDICAL, PA
Entity type:Organization
Organization Name:E.P. CORTEZ MEDICAL, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRYSTA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-327-4484
Mailing Address - Street 1:523 HARKRIDER ST
Mailing Address - Street 2:P.O. BOX 506
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-5631
Mailing Address - Country:US
Mailing Address - Phone:501-327-4484
Mailing Address - Fax:501-327-5963
Practice Address - Street 1:523 HARKRIDER ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-5631
Practice Address - Country:US
Practice Address - Phone:501-327-4484
Practice Address - Fax:501-327-5963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE5240174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty