Healthcare Provider Details

I. General information

NPI: 1972613743
Provider Name (Legal Business Name): MCCRORY FAMILY CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 N EDMONDS AVE
MCCRORY AR
72101
US

IV. Provider business mailing address

PO BOX 780
MCCRORY AR
72101
US

V. Phone/Fax

Practice location:
  • Phone: 870-731-1100
  • Fax: 870-731-1019
Mailing address:
  • Phone: 870-731-1100
  • Fax: 870-731-1019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License NumberMC-1803
License Number StateAR

VIII. Authorized Official

Name: FRED E WILSON
Title or Position: MD
Credential: MD
Phone: 870-731-1100