Healthcare Provider Details

I. General information

NPI: 1366422305
Provider Name (Legal Business Name): MONTICELLO MEDICAL CLINIC PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 04/01/2020
Certification Date: 04/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 ROBERTS DR
MONTICELLO AR
71655-5724
US

IV. Provider business mailing address

906 ROBERTS DR
MONTICELLO AR
71655-5724
US

V. Phone/Fax

Practice location:
  • Phone: 870-367-6867
  • Fax: 870-367-1461
Mailing address:
  • Phone: 870-367-6867
  • Fax: 870-367-1461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SYLVIA SIMON
Title or Position: PARTNER
Credential: MD
Phone: 870-367-6867