Healthcare Provider Details

I. General information

NPI: 1710225545
Provider Name (Legal Business Name): BAPTIST HEALTH FAMILY CLINIC PROTHO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2013
Last Update Date: 01/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5207 E BROADWAY ST
NORTH LITTLE ROCK AR
72117-4029
US

IV. Provider business mailing address

11001 EXECUTIVE CENTER DR SUITE 200
LITTLE ROCK AR
72211-4316
US

V. Phone/Fax

Practice location:
  • Phone: 501-945-2033
  • Fax: 501-945-2303
Mailing address:
  • Phone: 501-812-7512
  • Fax: 501-812-7507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberR2917
License Number StateAR

VIII. Authorized Official

Name: MR. WILL RUSHER
Title or Position: CEO
Credential:
Phone: 501-812-7512