Healthcare Provider Details

I. General information

NPI: 1487313557
Provider Name (Legal Business Name): MEDGEN NEURO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2021
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 N CREEK DR
CONWAY AR
72032-4711
US

IV. Provider business mailing address

824 N CREEK DR
CONWAY AR
72032-4711
US

V. Phone/Fax

Practice location:
  • Phone: 999-999-9999
  • Fax:
Mailing address:
  • Phone: 999-999-9999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DEANNE GOSS
Title or Position: MANAGING MEMBER
Credential:
Phone: 999-999-9999