Healthcare Provider Details

I. General information

NPI: 1285119198
Provider Name (Legal Business Name): SAINT MARYS PRIMARY CARE NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2018
Last Update Date: 12/12/2019
Certification Date: 12/12/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W C PL
RUSSELLVILLE AR
72801-2705
US

IV. Provider business mailing address

1600 W C PL
RUSSELLVILLE AR
72801-2705
US

V. Phone/Fax

Practice location:
  • Phone: 479-967-7717
  • Fax: 866-280-8464
Mailing address:
  • Phone: 479-967-7717
  • Fax: 866-280-8464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHY J. TEAGUE
Title or Position: SECRETARY
Credential:
Phone: 615-920-7000