Healthcare Provider Details

I. General information

NPI: 1679784367
Provider Name (Legal Business Name): SPARKS REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 DODSON AVE STE 290
FORT SMITH AR
72901-5182
US

IV. Provider business mailing address

PO BOX 1824
FORT SMITH AR
72902-1824
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number239
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateAR

VIII. Authorized Official

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