Provider Demographics
NPI:1912995606
Name:KRISH FAMILY CLINIC
Entity Type:Organization
Organization Name:KRISH FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MADHULIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRISH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-289-5865
Mailing Address - Street 1:PO BOX 295
Mailing Address - Street 2:
Mailing Address - City:LOCKESBURG
Mailing Address - State:AR
Mailing Address - Zip Code:71846-0295
Mailing Address - Country:US
Mailing Address - Phone:870-289-5865
Mailing Address - Fax:870-289-6993
Practice Address - Street 1:1357 W COLLIN RAYE DR
Practice Address - Street 2:
Practice Address - City:DE QUEEN
Practice Address - State:AR
Practice Address - Zip Code:71832-2946
Practice Address - Country:US
Practice Address - Phone:870-642-4343
Practice Address - Fax:870-642-4399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3302207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146878002Medicaid
AR5C674OtherBCBS
AR5C674Medicare PIN