MEDICARE: EMERGENCY MEDICINE OF NORTHWEST ARKANSAS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician
2	207P00000X	Emergency Medicine Physician		AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	5G278	OTHER	AR	ARKANSAS BLUE CROSS

General Provider Information

NPI Number	:	1538486113
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMERGENCY MEDICINE OF NORTHWEST ARKANSAS, LLC

Provider Business Mailing Address
First Line	:	3873 NORTH PARKVIEW DRIVE
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703
Country	:	US
Telephone Number	:	479-466-0432
Fax Number	:

Provider Business Practice Location Address
First Line	:	3873 NORTH PARKVIEW DRIVE
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703
Country	:	US
Telephone Number	:	479-466-0432
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JEFF M AUDIBERT
Credential	:	M.D.
Telephone Number	:	479-633-4102

Provider Enumeration Date	:	04/22/2010
Last Update Date	:	11/18/2016

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