Healthcare Provider Details

I. General information

NPI: 1063626117
Provider Name (Legal Business Name): ST MARYS PHYSICIAN SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SKYLINE DR
RUSSELLVILLE AR
72801-3363
US

IV. Provider business mailing address

101 SKYLINE DR
RUSSELLVILLE AR
72801-3363
US

V. Phone/Fax

Practice location:
  • Phone: 479-968-2345
  • Fax: 479-890-2497
Mailing address:
  • Phone: 479-968-2345
  • Fax: 479-890-2497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: CHARLOTTE LAWRENCE
Title or Position: SECRETARY
Credential:
Phone: 615-920-7000