Provider Demographics
NPI:1649396979
Name:FORREST CITY FAMILY PRACTICE CLINIC, PA
Entity type:Organization
Organization Name:FORREST CITY FAMILY PRACTICE CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NEIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-737-3071
Mailing Address - Street 1:902 HOLIDAY DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORREST CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72335-9183
Mailing Address - Country:US
Mailing Address - Phone:870-630-1256
Mailing Address - Fax:
Practice Address - Street 1:902 HOLIDAY DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-9183
Practice Address - Country:US
Practice Address - Phone:870-630-1256
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR3762207QA0000X, 207QG0300X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Single Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARR3762OtherBCBS GROUP ID
AR51280OtherBCBS INDV NUMBER
AR113530001Medicaid
AR113530001Medicaid
AR113530001Medicaid
=========OtherTAX ID
DO4484Medicare UPIN