Healthcare Provider Details

I. General information

NPI: 1356317440
Provider Name (Legal Business Name): SOUTH ARK EAR NOSE &THROAT CLINIC P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1722 W 42ND AVE
PINE BLUFF AR
71603-7008
US

IV. Provider business mailing address

1722 W 42ND AVE
PINE BLUFF AR
71603-7008
US

V. Phone/Fax

Practice location:
  • Phone: 870-535-5719
  • Fax: 870-536-1963
Mailing address:
  • Phone: 870-535-5719
  • Fax: 870-536-1963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberMC1312
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberA#283
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberA#283
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberMC1312
License Number StateAR
# 5
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMC1312
License Number StateAR

VIII. Authorized Official

Name: STEPHEN DONALD SHORTS
Title or Position: PRESIDENT
Credential: MD
Phone: 870-535-5719