Healthcare Provider Details

I. General information

NPI: 1093795031
Provider Name (Legal Business Name): ARKANSAS OTOLARYNGOLOGY CENTER, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 05/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 KANIS RD
LITTLE ROCK AR
72205-6203
US

IV. Provider business mailing address

10201 KANIS RD
LITTLE ROCK AR
72205-6203
US

V. Phone/Fax

Practice location:
  • Phone: 501-227-5050
  • Fax: 501-227-5151
Mailing address:
  • Phone: 501-227-5050
  • Fax: 501-227-5151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberAR3809
License Number StateAR

VIII. Authorized Official

Name: DELAINE MARTIN
Title or Position: OFFICE MANAGER
Credential:
Phone: 501-227-5050