Healthcare Provider Details

I. General information

NPI: 1174044952
Provider Name (Legal Business Name): DR. STEPHEN C. FISHER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1359 E MAIN ST
CLARKSVILLE AR
72830-9554
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 479-744-6900
  • Fax:
Mailing address:
  • Phone: 479-498-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. STEPHEN C FISHER
Title or Position: SOLE MBR
Credential: DDS
Phone: 479-518-5111