Healthcare Provider Details

I. General information

NPI: 1902939598
Provider Name (Legal Business Name): PHYSICIAN'S MANAGEMENT GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 W MAIN ST
JACKSONVILLE AR
72076-4214
US

IV. Provider business mailing address

2520 W MAIN ST
JACKSONVILLE AR
72076-4214
US

V. Phone/Fax

Practice location:
  • Phone: 501-982-0528
  • Fax: 501-985-7777
Mailing address:
  • Phone: 501-982-0528
  • Fax: 501-985-7777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: ANDREA M MAXEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 50198205285