Healthcare Provider Details

I. General information

NPI: 1356549984
Provider Name (Legal Business Name): ROGER D SIMONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E MAIN PLACE SUITE 3
FLIPPIN AR
72634
US

IV. Provider business mailing address

PO BOX 550
FLIPPIN AR
72634-0550
US

V. Phone/Fax

Practice location:
  • Phone: 870-453-2274
  • Fax:
Mailing address:
  • Phone: 870-453-2274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR4272
License Number StateAR

VIII. Authorized Official

Name: ROGER D SIMONS
Title or Position: OWNER
Credential: M.D.
Phone: 870-453-2274