Healthcare Provider Details

I. General information

NPI: 1578045803
Provider Name (Legal Business Name): BLUETAIL ARKANSAS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 11/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9101 KANIS RD STE 200
LITTLE ROCK AR
72205-6455
US

IV. Provider business mailing address

C/O BLUETAIL MEDICAL GROUP, LLC 17300 NORTH OUTER 40 RD, STE 201
CHESTERFIELD MO
63005-1364
US

V. Phone/Fax

Practice location:
  • Phone: 636-778-2900
  • Fax: 636-778-2828
Mailing address:
  • Phone: 636-778-2900
  • Fax: 636-778-2828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KRISTIN S OLIVER
Title or Position: OWNER
Credential: MD
Phone: 636-778-2900