Healthcare Provider Details

I. General information

NPI: 1730486556
Provider Name (Legal Business Name): ST. EDWARD MERCY CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2011
Last Update Date: 12/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 WE KNIGHT DRIVE
FORT SMITH AR
72903-6248
US

IV. Provider business mailing address

PO BOX 11230
FORT SMITH AR
72917-1230
US

V. Phone/Fax

Practice location:
  • Phone: 479-709-6700
  • Fax: 479-709-6709
Mailing address:
  • Phone: 479-709-6767
  • Fax: 479-709-6768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. RAYMOND COLE GOODMAN JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 479-314-6100