Healthcare Provider Details

I. General information

NPI: 1962450007
Provider Name (Legal Business Name): SPARKS MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 11/01/2007
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: 479-709-7404
  • Fax: 479-709-7418
Mailing address:
  • Phone: 479-709-7399
  • Fax: 479-709-7057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code2085R0205X
TaxonomyRadiological Physics Physician
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State

VIII. Authorized Official

Name: REBECCA COX
Title or Position: CBO SUPPORT MANAGER
Credential:
Phone: 479-709-7057