Healthcare Provider Details

I. General information

NPI: 1962478115
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: 08/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4310 S MULBERRY ST
PINE BLUFF AR
71603-7030
US

IV. Provider business mailing address

4310 S MULBERRY ST
PINE BLUFF AR
71603-7030
US

V. Phone/Fax

Practice location:
  • Phone: 870-535-5177
  • Fax: 870-535-7878
Mailing address:
  • Phone: 870-535-5177
  • Fax: 870-535-7878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number850
License Number StateAR

VIII. Authorized Official

Name: STEPHEN DONALD SHORTS
Title or Position: PRESIDENT
Credential: MD
Phone: 870-535-5177