Healthcare Provider Details

I. General information

NPI: 1275541427
Provider Name (Legal Business Name): PINE BLUFF ENDOSCOPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 11/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 W 40TH AVE SUITE 312
PINE BLUFF AR
71603-6319
US

IV. Provider business mailing address

1609 W 40TH AVE SUITE 312
PINE BLUFF AR
71603-6319
US

V. Phone/Fax

Practice location:
  • Phone: 870-534-2626
  • Fax: 870-534-3517
Mailing address:
  • Phone: 870-534-2626
  • Fax: 870-534-3517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License NumberAR4347
License Number StateAR

VIII. Authorized Official

Name: O.T. GORDON JR.
Title or Position: MANAGING MEMBER
Credential: M.D.
Phone: 870-534-3344