Healthcare Provider Details

I. General information

NPI: 1043308935
Provider Name (Legal Business Name): BOARD OF GOVERNORS OF DALLAS COUNTY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 08/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 NORTH CLIFTON STREET
FORDYCE AR
71742
US

IV. Provider business mailing address

201 NORTH CLIFTON STREET
FORDYCE AR
71742
US

V. Phone/Fax

Practice location:
  • Phone: 870-352-6363
  • Fax: 870-352-6343
Mailing address:
  • Phone: 870-352-6363
  • Fax: 870-352-6343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberAR4114
License Number StateAR

VIII. Authorized Official

Name: TAMARA K RIEVES
Title or Position: ADMINISTRATOR / CEO
Credential:
Phone: 870-352-6363