Healthcare Provider Details

I. General information

NPI: 1932619327
Provider Name (Legal Business Name): FORT NEURO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2017
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S WALDRON RD STE 109
FORT SMITH AR
72903-2568
US

IV. Provider business mailing address

1501 S WALDRON RD STE 109
FORT SMITH AR
72903-2568
US

V. Phone/Fax

Practice location:
  • Phone: 479-242-3310
  • Fax: 479-439-8868
Mailing address:
  • Phone: 479-242-3310
  • Fax: 479-439-8868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY Y MARYANOV
Title or Position: OWNER
Credential: MD
Phone: 479-242-3310