Healthcare Provider Details

I. General information

NPI: 1740906593
Provider Name (Legal Business Name): MICHAEL VASILJ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 LILE CT STE 200
LITTLE ROCK AR
72205-6240
US

IV. Provider business mailing address

20400 COLONEL GLENN RD
LITTLE ROCK AR
72210-5323
US

V. Phone/Fax

Practice location:
  • Phone: 501-663-1837
  • Fax: 501-663-1839
Mailing address:
  • Phone: 501-821-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: