=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023902921
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INFECTIOUS DISEASES SERVICES OF ARKANSAS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2025
-----------------------------------------------------
Last Update Date | 06/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | INFECTIOUS DISEASES SERVICES OF ARKANSAS, LLC 3416 OLD GREENWOOD RD, SUITE #B
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-652-7973
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | INFECTIOUS DISEASES SERVICES OF ARKANSAS LLC 2316 DUNDEE DRIVE
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-652-7973
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | RAED N. KHAIRY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 479-652-7973
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------