Provider Demographics
NPI:1396996740
Name:ARKANSAS CENTRAL PRIMARY CARE, PLLC
Entity type:Organization
Organization Name:ARKANSAS CENTRAL PRIMARY CARE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:DREW
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-985-5994
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72078-0309
Mailing Address - Country:US
Mailing Address - Phone:501-985-5900
Mailing Address - Fax:501-985-6016
Practice Address - Street 1:1300 BRADEN ST.
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-3719
Practice Address - Country:US
Practice Address - Phone:501-985-5900
Practice Address - Fax:501-985-6016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-03
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR176116002Medicaid
AR142734002Medicaid
AR142734002Medicaid
AR176116002Medicaid