Healthcare Provider Details

I. General information

NPI: 1982696464
Provider Name (Legal Business Name): JONATHAN T GHORMLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 12/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 CLUB LANE SUITE 1
CONWAY AR
72034-3681
US

IV. Provider business mailing address

550 CLUB LANE SUITE 1
CONWAY AR
72034-3681
US

V. Phone/Fax

Practice location:
  • Phone: 501-329-1510
  • Fax: 501-329-5697
Mailing address:
  • Phone: 501-329-1510
  • Fax: 501-329-5697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberR3946
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: