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General NPI Number Information
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NPI Number | 1104106426
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Entity Type | Organization
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Legal Business Name | SHANE HIGGINBOTHAM MD PA
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Dates
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Enumeration Date | 08/17/2011
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Last Update Date | 08/02/2023
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Provider Practice Location Address
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Address Line | 1580 TANNER ST
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City | ROCKPORT
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State | AR
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Zip | 72104-2023
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Country | US
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Telephone | 501-337-9994
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Fax | 501-337-9964
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Provider Business Mailing Address
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Address Line | 1580 TANNER ST
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City | ROCKPORT
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State | AR
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Zip | 72104-2023
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Country | US
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Telephone | 501-337-9994
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Fax | 501-337-9964
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | KIM OVERTON
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Credential |
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Telephone | 501-337-9994
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | E0968
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License Number State | AR
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