Provider Demographics
NPI:1881776987
Name:UNIVERSITY OF ARKANSAS MEDICAL SCIENCES, AHEC PINE BLUFF
Entity type:Organization
Organization Name:UNIVERSITY OF ARKANSAS MEDICAL SCIENCES, AHEC PINE BLUFF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:KITTELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-541-6000
Mailing Address - Street 1:12 SEZANNE CV
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-5093
Mailing Address - Country:US
Mailing Address - Phone:501-821-7795
Mailing Address - Fax:
Practice Address - Street 1:4747 DUSTY LAKE DR
Practice Address - Street 2:STE 203
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-8742
Practice Address - Country:US
Practice Address - Phone:870-541-9300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE5801261QE0002X, 261QP2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARE-5801OtherARKANSAS STATE MEDICAL BOARD
AR440144201Medicaid