Healthcare Provider Details

I. General information

NPI: 1104041292
Provider Name (Legal Business Name): ROBERT A. COUNCIL, JR., MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 09/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PARK DR
BENTON AR
72015-3353
US

IV. Provider business mailing address

PO BOX 9150
PADUCAH KY
42002-9150
US

V. Phone/Fax

Practice location:
  • Phone: 501-776-6901
  • Fax: 501-776-6908
Mailing address:
  • Phone: 270-744-9600
  • Fax: 270-744-0834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT A. COUNCIL JR.
Title or Position: OWNER
Credential: M.D.
Phone: 501-776-5070