Healthcare Provider Details

I. General information

NPI: 1316131048
Provider Name (Legal Business Name): DREW PROFESSIONAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 HL ROSS DRIVE
MONTICELLO AR
71655-5705
US

IV. Provider business mailing address

750 HL ROSS DRIVE
MONTICELLO AR
71655
US

V. Phone/Fax

Practice location:
  • Phone: 870-460-3514
  • Fax: 870-460-3565
Mailing address:
  • Phone: 870-460-3514
  • Fax: 870-460-3565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: VONDA RUSSELL
Title or Position: BUSINESS OFFICE DIRECTOR
Credential:
Phone: 870-460-3514