Healthcare Provider Details

I. General information

NPI: 1881776987
Provider Name (Legal Business Name): UNIVERSITY OF ARKANSAS MEDICAL SCIENCES, AHEC PINE BLUFF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 08/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4747 DUSTY LAKE DR STE 203
PINE BLUFF AR
71603-8742
US

IV. Provider business mailing address

12 SEZANNE CV
LITTLE ROCK AR
72223-5093
US

V. Phone/Fax

Practice location:
  • Phone: 870-541-9300
  • Fax:
Mailing address:
  • Phone: 501-821-7795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License NumberE5801
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberE5801
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL TIMOTHY KITTELL
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 870-541-6000