Provider Demographics
NPI:1457077356
Name:DIRECT MD, LLC
Entity Type:Organization
Organization Name:DIRECT MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:M
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-978-8604
Mailing Address - Street 1:1701 S SHACKLEFORD RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4335
Mailing Address - Country:US
Mailing Address - Phone:501-219-7000
Mailing Address - Fax:
Practice Address - Street 1:2223 GRANT ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-4700
Practice Address - Country:US
Practice Address - Phone:501-337-9031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-13
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty