Provider Demographics
NPI:1740262732
Name:COLLOM & CARNEY CLINIC
Entity type:Organization
Organization Name:COLLOM & CARNEY CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:DWIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:CCS-P, MHA, CMPE
Authorized Official - Phone:903-614-3282
Mailing Address - Street 1:5002 COWHORN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9766
Mailing Address - Country:US
Mailing Address - Phone:903-614-3000
Mailing Address - Fax:903-614-3525
Practice Address - Street 1:1440 W 1ST N
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AR
Practice Address - Zip Code:71853
Practice Address - Country:US
Practice Address - Phone:870-887-8001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLLOM & CARNEY CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-16
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149724002Medicaid
CC9231OtherRAILROAD MEDICARE
AR5B878Medicare PIN