Healthcare Provider Details

I. General information

NPI: 1073788212
Provider Name (Legal Business Name): STACY R TAIT PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5518 ELLSWORTH RD
FORT SMITH AR
72903-3222
US

IV. Provider business mailing address

2201 WYNDEMERE WAY
FORT SMITH AR
72903
US

V. Phone/Fax

Practice location:
  • Phone: 501-771-4693
  • Fax: 501-771-4885
Mailing address:
  • Phone: 501-771-4693
  • Fax: 501-771-4885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: STACY TAIT
Title or Position: SELF
Credential: M.D.
Phone: 501-771-4693