Healthcare Provider Details

I. General information

NPI: 1386634285
Provider Name (Legal Business Name): SPARKS MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 10/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 DODSON AVE
FORT SMITH AR
72901-5182
US

IV. Provider business mailing address

PO BOX 2420
FORT SMITH AR
72902-2420
US

V. Phone/Fax

Practice location:
  • Phone: 479-709-7399
  • Fax: 479-709-7053
Mailing address:
  • Phone: 479-709-7399
  • Fax: 479-709-7053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 15
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: REBECCA FRIDDLE
Title or Position: SPARKS PROVIDER RELATIONS MANAGER
Credential:
Phone: 479-709-7057