Provider Demographics
NPI:1932586260
Name:ARKANSAS LIVER AND GASTROENTEROLOGY PA
Entity Type:Organization
Organization Name:ARKANSAS LIVER AND GASTROENTEROLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:JESSICA-ELISE
Authorized Official - Last Name:COLUCCINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-242-2888
Mailing Address - Street 1:3416 OLD GREENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5462
Mailing Address - Country:US
Mailing Address - Phone:352-871-0992
Mailing Address - Fax:
Practice Address - Street 1:3416 OLD GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5462
Practice Address - Country:US
Practice Address - Phone:479-242-2888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-06
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-7210261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center