Provider Demographics
NPI:1801017595
Name:EVERGREEN INTERNAL MEDICINE PLLC
Entity type:Organization
Organization Name:EVERGREEN INTERNAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-664-1540
Mailing Address - Street 1:1100 N UNIVERSITY AVE
Mailing Address - Street 2:SUITE 125
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72207-6343
Mailing Address - Country:US
Mailing Address - Phone:501-664-1540
Mailing Address - Fax:
Practice Address - Street 1:1100 N UNIVERSITY AVE
Practice Address - Street 2:SUITE 125
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72207-6343
Practice Address - Country:US
Practice Address - Phone:501-664-1540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C418Medicare ID - Type Unspecified