=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043495286
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARKANSAS CANCER CLINIC - RADIATION ONCOLOGY, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2008
-----------------------------------------------------
Last Update Date | 01/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7200 S HAZEL ST
-----------------------------------------------------
City | PINE BLUFF
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71603-7836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-535-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7200 S HAZEL ST
-----------------------------------------------------
City | PINE BLUFF
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71603-7836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-535-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS OFFICE MANAGER
-----------------------------------------------------
Name | ROBIN COPE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 870-535-2800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | E3352
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------